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J)ISEASES 


OF    THE 


INTESTINES 


AND 


PERITONEUM. 


BY 


JOHN  SYER  BRISTOWE,  M.D. 

// 
J.  R.  WARDELL,  M.D.,  J.  W.  BEGBIE,  M.D. 

S.  O.  HABERSHON,  M.D. 

T.  B.  CURLING,  F.RS.,    and    W.  H.  RANSOM,  M.D. 


NEW    YORK 

WILLIAM   WOOD    &    COMPANY 

1879 


COPYTIIOHT,    TJT 

WILLIAM    WOOD  ii    COMPANY, 
1B79. 


Trow*s 

Printing  and  Bookbinding  COm 

805-213  Katt  13th  St., 

NEW  VOBK. 


CONTENTS. 


Enteralgia,  Definition  — Synonyms — Causes — Symptoms — Pathology — Diagno- 
sis— Treatment 1-8 

Enteritis,  As  a£Eecting  the  Serous  and  Muscular  Coats — As  affecting  the  Mu- 
cous Membrane — (a)  Catarrhal  Inflammation,  (J)  Croupous  Inflammation, 
(c)  Chronic  Inflammation  and  Degeneration — As  affecting  the  whole  thickness 
of  the  Bowels — Treatment 9-17 

Obstruction  of  the  Bowels,  Constipation — (a)  Pathology  and  Symptoms, 
{b)  Treatment — Stricture,  (a)  Pathology,  (6)  Symptoms,  (c)  Treatment — Com- 
pression and  Traction,  (a)  Pathology,  {b)  Symptoms  and  Treatment — Internal 
Strangulation,  (a)  Pathology,  (6)  Symptoms,  (c)  Treatment,  (rf)  Note  ou 
Torsion  or  Twisting  of  Bowel — Impaction  of  Foreign  Bodies,  (a)  Pathology, 
(6)  Symptoms  and  Treatment — Intussusception,  (a)  Pathology,  (b)  Symptoms, 
(c)  Treatment — Concluding  Remarks,  {a)  Pain,  (b)  Vomiting,  (c)  Constipation, 
{d)  Tumor  and  Shape  of  Belly,  {e)  Condition  of  Urine,  (/)  The  Mode  of  In- 
vasion, ((/)  The  Duration  of  Life,  (A)  Statistics,  {i)  Finally,  in  Respect  of 
Treatment 19-49 

Ulceration  of  the  Bowels — ^Pathology — (a)  Ulceration  beginning  from  within, 

(b)  Ulceration  beginning  from  without — Symptoms — Treatment 51-60 

Cancerous  and  other  Growths  op  the  Intestines— Cancerous  Disease — 
Fibroid  Infiltration  and  Thickening — Villous  Growths — Polypi  — Other 
Growths 61-M 

Diseases  op  the  Caecum  and  Appendix  Vermiformis — General  Account  of 
Diseases  of  Cascum  and  Appendix — Ulceration  and  Perforation  of  the  C«cum 
and  Vermiform  Appendix,  {a)  Pathology,  {b)  Symptoms,  (c)  Treatment 65-71 

Colic — Definition — Symptomatology   of    Colic — Pathology  of  Colic — Etiology  of 

Colic— Treatment  of  Colic    73-77 

Colitis 79 

DiARRHCEA — Diarrhoea  Crapulosa — Bilious  Diarrhoea — Catarrhal  and  Mucous  Di- 
aiThoea — Morbid  Anatomy — Dysenteric  Diarrhoea — Choleraic  Diarrhoea — Dis- 
charge of  Blood,  or  Metena — Symptoms  of  Diarrhoea — Causes,  (a)  Exposure 
{b)  Improper  food,  {cj  Exhaustion,  (d)  Epidemic  Causes,  {e}  Endemic  Causes, 
(/)  Excessive  Secretion  of  Bile,  (g)  Other  Causes,  Prognosis — Diagnosis — 
Treatment,  (a)  Warmth,  (b)  Food,  (c)  Stimulants,  {d)  Rest,  {e)  Air — To  restore 
the  Diseased  Mucous  Membrane  and  to  correct  Secretions,  (a)  Alkalies,  (b) 
Mercurials,  (c)  Demulcents,  (d)  Castor  Oil,  Linseed  OU,  (e)  Ipecacuanha,  (/) 
Astringents  and  Desiccants,  (g)  Opium,  {h)  Mineral  Acids,  (i)  Leeches,  (j) 
Suppositories,  Cases..    81-93 


IV  CONTENTS. 

Dtskntkrt — Definition — Synonyms  — History — Symptomatology — Chronic  Dys- 
entery—Morbid Anatomy — Etiology — Treatment 95-106 

Duodenum — State  of  Secretion — Congenital  Malformation — Congestion — XJlcera- 

tion — Cancerous  Disease — Mechanical  Obstruction 107-128 

Diseases  of  the  Rectum  and  Anus.  Congenital  Imperfections — Hasmorrhoida 
— Prolapsus  of  the  Rectum — Irritable  Ulcer  and  Fissure — Irritable  Sphincter 
Muscle — Nervous  Affections  of  the  Rectum,  (1)  Irritable  Rectum,  (2)  Morbid 
Sensibility  of  Rectum,  (3)  Neuralgia  of  Rectum — Villous  Tumor  of  Rectum 
—Polypus  of  the  Rectum — Fistula — Chronic  Ulceration  of  the  Rectum — Stric- 
ture of  Rectum — Cancer  of  Rectum — Epithelial  Cancer  of  the  Anus  and  Rec- 
tum— ^Atony  of  the  Rectum — Anal  Tumors  and  Excrescences — Prurigo 
anL 129-151 

iHTKSTlNAli  Worms — Introductory  Remarks — History — Taenia  Solium — Taenia 
Medio-Canellata  —  Bothriocephalus  Latus  —  Taenia  Nana  —  Taenia  Flavo- 
punctata — Taenia  EUiptica  —  Bothriocephalus  Cordatus  —  Ascaris  Lumbri- 
coides — Ascaris  Myspax — Oxyuria  Vermicnlaria — Dochmias  Duodenalis — Tri- 
chocephalua  Dispar 153-175 

Pkritonitis — Definition — Preliminary  Observations — Etiology — Symptomatology 
— "Varieties — Morbid  Anatomy — Diagnosis — Prognosis — Treatment 177-211 

Tubercle  op  the  Peritoneum— Pathology — Symptoms 213-217 

Carcinoma  of  the  Peritoneum — Pathology — Symptoms — Treatment 219-222 

Affections  of  the  Abdominal  Lymphatic  Glands 223-224 

Ascites- Pathology — Symptoms — Treatment 225-232 

Abdominal  Tumors — Phantom  Tumors — Tumors  in  the  Right  Hypochondrinm — 
— Tumors  in  the  Epigastric  Region — Tumors  in  the  Left  Hypochondrinm — 
Tumors  in  the  Lumbar  Regions — In  the  Umbilical  Region — In  the  Hypogas- 
tric Region— In  the  Right  Iliac  Region — In  the  Left  Iliac  Region 233-240 


DISEASES    OF    THE 

INTESTINES  AND  PERITONEUM. 


ENTERALGIA. 

By  John  Richaed  Waedell,  M.D.,  F.R.C.P. 


Definttion'. — Enteralgia  is  a  painful  affection  of  the  intestines,  of 
neuralgic  character,  generally  accompanied  with  constipation  and  flatus. 
It  may  come  on  gradually  in  a  dull  and  obtuse  manner,  but  in  the  great 
majority  of  instances  its  supervention  is  sudden,  and  the  pain  is  sharp  and 
violent.  It  is,  correctly  speaking,  visceral  neuralgia,  and  mostly  occurs 
in  neurotic  individuals.  The  common  accompaniments  of  inflammation 
are  absent.  The  skin  is  cool,  the  pulse  is  not  accelerated,  and  the  heart's 
impulse  is  rather  subdued  than  augmented.  Its  attacks  are  paroxysmaL 
It  shifts  its  position  in  the  abdomen.  It  is  often  a  pain  reflected  by  distal 
disease,  but  if  continuous  it  may  end  in  inflammation. 

Synonyms. — Enteralgia,  Tormina,  Dolor,  Colicus,  Colicodynia,  Spasmus 
Intestinorum  {various  authors),  Ileus  [Saicvages),  Spasmus  Ventriculi 
(  W^iessner).  Some  writers  have  confounded  it  with  Gastrodynia,  or  Gas- 
tralgia.  In  the  vernacular  the  affection  is  identical  with  Pain  of  the 
Intestines,  Spasm  of  the  Bowels  and  Belly-ache,  Pain  in  the  Belly,  Gripes, 
and  Cholick,  or  Cholick  Colic. 

Causes. — The  causes  of  this  complaint  are  to  be  regarded  as  those 
which  are  Predisposing  or  Remote,  and  those  which  are  Proximate  or  Ex- 
citiuff. 

Under  the  head  of  the  first-named  may  be  mentioned  the  influence  of 
sex,  and  it  is  beyond  dispute  that  females  are  more  prone  to  this  affection 
than  males;  their  greater  sensitiveness,  and  their  susceptibility  to  moral 
emotions,  favor  the  development  of  nervous  diseases;  and  the  sympathy 
of  the  uterus  and  its  appendages,  as  familiarly  known,  in  marked  manner 
reacts  upon  the  cerebro-spinal  and  ganglionic  systems.  The  particular 
temperament  of  the  patient  will  confer  a  proneness  to,  or  tend  to  give  an 
immunity  from,  this  complaint;  those  who  are  nervous  and  melancholic 
being  more  liable  to  it,  and  those  who  are  leuco-phlegmatic  or  lymphatic 
being  less  susceptible.  The  condition  of  asthenia  conduces  to  the  pro- 
duction of  enteralgia,  and  a  lowered  vitalism  is  often  associated  with  an 
exaltation  of  sensibility.     The  weakness  resulting  from  acute  or  chronic 


2  DISEASES    OF    THE   INTESTINES    AND    PERITONEUM. 

disease,  by  depressing  the  tone  of  the  system  in  general,  and  the  function:il 
power  of  the  great  nervous  centres  in  particular,  constitutes  a  common 
predisponent,  and  the  morbid  action  of  the  ner%es  proper  to  some  part  or 
parts  is  not  an  unusual  occurrence.  During  the  convalescence  of  fever, 
after  visceral  inflammation  and  large  losses  of  blood  these  attacks  are  not 
frequently  witnessed.  Excessive  lactation,  by  subduing  the  general 
strength,  often  enters  as  an  element  into  the  remote  causation;  and  the 
same  may  be  said  of  menorrhagia,  the  lochia,  hemorrhoids,  leucorrhcea, 
and  like  affections.  Long-continued  secretions  and  periodical  discharges, 
by  deteriorating  and  diminishing  the  vital  iluids,  are  followed  by  the 
result  in  question.  Amongst  the  proximate  or  exciting  causes  is  to  be 
mentioned  the  malarial  iniluence,  and  in  tropical  countries  and  aguish 
districts  there  is  no  doubt  it  often  merits  the  accusation.  Atmospheric 
humidity,  low  and  damp  situations,  and  a  naturally  cold  and  wet  climate, 
form  endemic  conditions  which  foster  the  development  of  neuralgic  ail- 
ments; and  the  truth  of  the  converse  is  unquestionable  that  in  places  of 
greater  altitude,  and  in  a  purer  and  drier  air  they  are  not  so  prevalent. 
When  hot  and  sunny  days  are  followed  by  frosty  nights,  the  body  being 
suddenly  chilled,  and  thus  the  blood  being  determined  to  the  internal 
organs,  these  anomalous  pains  are  often  produced.  Wet  clothes  and  wet 
feet  give  rise  to  the  same  affection.  Mental  fatigue,  as  after  long-con- 
tinued and  great  intellectual  efforts,  has  by  some  writers  been  enumerated. 
In  those  persons  whose  vocations  are  such  as  to  demand  a  continued  strain 
of  thought,  or  whose  hopes  and  fears  are  excited  by  speculation,  as  in 
commercial  enterprises,  or  those  whose  faculties  are  stimulated  by  some 
career  of  ambition,  in  all  of  whom  the  nervous  functions  are  brought  into 
great  energy  of  action,  these  neurotic  ailments  prevail,  sometimes  being 
located  in  one  organ  or  part,  sometimes  in  another. 

There  are  also  proximate  causes,  which  are  strictly  speaking  patho- 
logical— which  are  referable  to  foregoing  and  obvious  forms  of  morbid 
change,  especially  to  those  changes  which  take  place  in  the  blood,  and 
which  constitute  a  humoral  causation  to  the  nervous  phenomena.  It  has 
been  observed  by  Simon  that  central  neuralgia  arises  with  the  utmost  fre- 
quency in  ana3miated  and  debilitated  persons;'  and  we  know  how  apt  it 
is  to  follow  hemorrhage,  and  be  associated  with  malnutrition  when  no 
primary  structural  lesion  exists.  During  the  latency  of  the  gouty,  and 
in  the  rheumatic  diathesis,  when  the  materies  morbi  of  those  respective 
affections  has  accumulated  in  the  system,  before  its  explosive  decom- 
position has  been  evinced  by  local  inflammation  and  excessive  sccretional 
evacuation,  its  presence  may  be  such  as  to  generate  that  humoral  disorder, 
which  first  affects  the  cerebro-spinal  and  ganglionic  centres,  and  then  the 
nerves  proper  to  visceral  organs.  In  chorea,  which  is  consequent  upon 
some  perversion  in  the  development  of  the  blood,  caused  by  the  alteration 
of  physical  qualities,  or  the  chemical  relations  of  that  fluid,  or  it  may  be 
by  the  absolute  generation  of  some  new  product,  we  have  ample  testimony 
of  the  immediate  effect  produced  on  the  nervous  s^'st em.  And  in  Bright's 
disease  we  are  continually  presented  with  examples  of  the  same  con- 
sequence, caused  by  the  retention  of  effete  and  poisonous  matters  in  the 
circulation.  Dr.  Todd*  some  time  ago  pointed  out  the  fact  that  epilepsy, 
as  associated  with  this  renal  affection,  is  characterized  by  greater  severity 
in  its  seizures  the  longer  the  interval  between  the  fits,  because  the  irritant 

'  Lectures  on  General  Patholopy,  Loct  X. 
*Lu:iileian  Lectures  Medical  Gazeile,  lb49and  1850. 


ENTERALGIA.  3 

materials  revnlsed  into  the  circulation  are  then  in  accumulation  and  act  with 
greater  force.  The  fact  that  defective  blood- development,  or  its  contam- 
ination by  lesion  of  the  depurative  organs,  is  productive  of  nervous  dis- 
orders, is  well  shown  by  the  administration  of  suitable  remedies.  In 
anaemia  and  chorea  we  every  day  observe  the  beneficial  effects  of  ferrugi- 
nous medicines,  and  see  how  pains  diminish  in  degree  and  frequency,  and. 
how  the  disorderly  movements  of  the  voluntary  muscles  become  subdued. 
In  hyperaemia,  more  especially  in  that  form  which  has  been  denominated 
active  hypememia,  pressure  upon  the  nervous  filaments  gives  pain;  and 
although  such  far  more  frequently  obtains  with  tlie  solid  abdominal 
organs,  yet  it  doubtless  is  an  element  entering  into  the  causation  of  En- 
teralgia. 

In  organic  disease  of  the  brain  and  spinal  cord  pain  is  generally  re- 
flected to  some  distant  part,  and  such  is  the  common  case  in  lesion  of  the 
last-named  organ.  In  caries  of  the  vertebra,  as  1  have  in  repetition  ob- 
served, the  reflected  visceral  pain  has  been  a  constantly  recurring  sign. 
Some  years  ago  I  saw,  at  the  request  of  a  distinguished  provincial  sur- 
geon, a  lady  who  for  many  weeks  had  been  under  his  care,  and  whose  case 
he  regarded  as  one  of  persistent  Enteralgia  caused  by  some  offending 
ingesta  or  some  impaction  in  the  bowels.  I  believed,  however,  that  this 
pain  in  the  bowels  had  a  more  remote  origin — that  it  was  spinal.  The 
examination  after  death  revealed  vertebral  caries  and  softening  of  the 
cord.  Sometimes  the  distal  pain  can  be  traced  to  mechanical  injuries  of 
the  nerve-centres.  We  know  that  in  children  there  is  the  closest  con- 
nection between  encephalic  disease  and  disorder  of  the  bowels.  In  pri- 
mary disease  of  the  solid  abdominal  viscera,  especially  in  that  of  the  liver 
and  spleen,  irritation  is  not  infrequently  extended  to  the  intestines;  some- 
times neuralgic  pain  of  an  intermittent  or  remittent  character  eventuates; 
while  in  active  congestion  of  the  liver,  or  in  that  sudden  distention  of  the 
spleen  which  occurs  in  periodic  fever,  intestinal  pain  is  no  unusual  symp- 
tom. The  intimate  sympathy  which  subsists  between  these  parts  can  be 
well  understood  when  we  consider  their  ganglionic  connection. 

Amongst  the  more  common  causes  may  be  mentioned  indigestion  and 
flatulence.  When  the  ingesta  have  not  been  properly  converted  into 
chyme,  but  have  passed  down  into  the  lower  bowels  only  partly  disinte- 
grated, they  give  rise  to  irregular  spasmodic  attacks  of  pain  by  acting,  as 
it  were,  like  foreign  bodies  in  the  canal.  In  this  way  shell-fish,  dried  salt 
meats,  pork,  badly  cooked  food,  unripe  fruit,  crude  vegetables,  and  the 
like,  are  followed  by  the  affection.  That  flatus  very  often  produces 
Enteralgia  is  a  fact  so  familiar  as  scarcely  to  merit  comment;  but  num- 
bers of  the  older  authors  speak  of  this  cause  with  much  emphasis.' 
Wiessner  says  :  "  Flatus  similiter  etiam  ventriculum  doloribus  spasticis 
afficiunt,  Haec  enim  toti  tractui  intestinorum  molestissima  affectio  vel 
ipsi  ventriculo  proxirae  nocet,  vel  partium  distentione  stomacho  proxi- 
marum.  Ex  hisce  imprimis  colon  transversum,  ante  inferiorem  ventriculi 
curvaturam  extensum,  sedem  aeri  incluso  quam  maxime  incommodam 
parat."*  The  movement  of  gases  from  one  part  of  the  intestines  to 
another  accounts  for  the  shifting  of  the  pain.  Constipation  is  another 
and  frequent  cause  of  the  complaint.     Indurated  masses  of  fteces  become 

'  Rhodii  Obs.  Med.  cent.  iii.  Palav.  1657;  cent.  ii.  o'  s.  70.  Lientaud,  Hist.  Arat. 
Mtid.  tome  i.  p.  7 ;  Paris,  1767.  Marchand,  Diss,  de  Cardial.  llatuL  Axgent.  1754. 
Weikard,  Vermischte  med.  Schriftea,  Fraukf.  1778,  b.  ii.  p.  143. 

'  De  Spasmo  Ventriculi,  p.  13. 


4  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

impacted  in  the  cecum,  sigmoid  flexure,  or  transverse  colon,  and  attacks 
of  sharp,  twisting,  rolling  pain  come  on  from  time  to  time,  and  are  not 
permanently  relieved  until  the  irritative  contents  of  the  gut  have  been 
voided.  Sometimes  a  large  gall-stone  or  a  concretion  is  the  cause.  Mor- 
bid secretions,,  acrid  substances,  acerb  fruits,  septic  food,  such  as  putrid 
game  and  bad  cheese,  stimulating  liquors,  and  sour  drinks  are  liable  to 
produce  Enteralgia.  Chemical  agents  and  medicinal  compounds  are  fol- 
lowed by  a  like  result.  The  sensitive  fibriles  proper  to  the  lining  tunic  of 
the  digestive  tract,  by  coming  in  contact  with  the  fore-named,  become 
irritated,  and  there  may  be  great  pain  when  the  motor  nerves  are  but 
slightly  influenced  in  their  functions.  In  lead  poisoning  the  intestinal 
nerves  are  particularly  prone  to  exaltation  of  sensibility. 

SviirTOMS. — The  mode  of  accession  is  generally  sudden,  the  pain  being 
sharp,  shooting,  or  twisting;  but  in  some  instances  it  comes  on  more 
gradually,  and  a  rolling  or  aching  of  the  bowels  is  described.  The  affec- 
tion is  in  the  majority  of  cases  first  felt  at  the  umbilicus  or  in  the  right 
iliac  fossa.  The  paroxysms  increase  in  degree  and  frequency,  the  inter- 
vals from  suffering  being  irregular  and  of  varied  duration.  The  pain, 
especially  in  the  earlier  stage  of  the  attack,  alters  its  position.  It  is 
rather  relieved  than  aggravated  by  pressure.  The  skin  is  often  cool,  the 
face  pale,  and  the  pulse,  instead  of  being  accelerated,  is  rendered  slower 
than  natural.  In  the  severer  cases  the  stomach  sympathizes,  and  sickness 
and  vomiting  may  supervene;  and  when  the  malady  becomes  intensified 
and  the  agony  excessive,  the  entire  surface  is  bedewed  with  a  chill,  clammy 
perspiration,  the  extremities  becoming  cold  and  of  venous  hue,  and  tlie 
general  aspect  that  of  collapse.  Costiveness  is  the  common  accompani- 
ment, and  percussion  displays  an  overloaded  state  of  some  part  of  the 
colon,  generally  at  the  ca?cum  or  sigmoid  flexure.  When  flatus  is  the 
chief  cause,  there  is  intestinal  distention,  and  such  notably  obtains  in  the 
large  bowel.  On  palpation  nodulated  eminences  are  felt,  which  quickly 
alter  in  their  configuration,  and  which  are  caused  by  the  constricted  and 
distended  portions  of  the  tube.  Wrfh  the  expulsion  of  the  confined  gases 
the  patient  derives  signal  and  immediate  relief,  and  sometimes  the  amount 
evolved  is  very  considerable.  The  noisy  flatulent  movements — borbo- 
rygmi — which  are  often  heard  in  the  canal  frequently  constitute  a  marked 
symptom  in  hysterical  females  whose  prima?  viae  are  generally  disordered, 
and  whose  assimilative  functions  are  imperfectly  performed.  The  attacks 
of  Enteralgia  may  be  intermittent  or  remittent.  Sometimes  they  termi- 
nate with  ail  the  rapidity  with  which  they  were  ushered  in.  Although,  as 
a  rule,  Enteralgia  is  apyrexial  in  character,  yet  inflammation  sometimes 
occurs;  and  then  the  surface  is  warmer,  the  pain  more  fixed,  and  the  cir- 
culation excited.  In  hysterical  women  uterine  disorder  is  the  usual  con- 
comitant, and  the  enteralgic  pain  will  often  be  found  in  association  with 
spinal  tenderness.  In  such  instances  percussion  on  the  spinal  processes 
should  not  be  omitted,  and  not  infrequently  hyperfcsthesia  of  the  abdom- 
inal surface  is  a  prominent  sign.  When  the  subjective  symptoms  are 
referable  to  organic  disease,  and  are  evidently  reflected,  the  cerebro-spinal 
axis  and  the  solid  abdominal  organs  should  respectively  be  examined,  and 
the  kind  of  lesion  there  existent  be  as  far  as  possible  correctly  estimated. 
This  neuralgic  pain  of  the  intestines  is  occasionally  seen  as  a  symptom 
caused  by  ulceration  and  congestion  of  the  uterus;  and  it  may  come  on 
after  the  sudden  retrocession  of  cutaneous  eruptions  and  the  exanthemata; 
also,  as  before  remarked,  it  may  follow  profuse  critical  evacuations,  the 
repeated  loss  of  blood  by  hemorrhoids  or  other  sources  of  debility. 


ENTKRALGIA.  5 

The  symptoms  are  modified  or  terminated,  or  the  attacks  rendered 
less  recurrent,  by  the  accession  of  certain  morbid  conditions  taking  place 
in  the  system.  The  advent  of  a  powerful  diaphoresis,  the  supervention 
of  diarrhoea,  the  flow  of  the  catamenia,  the  lochial  discharge,  the  occur- 
rence of  epistaxis,  the  formation  of  an  abscess,  or  the  return  of  some 
long-habituated  secretion,  are  known  to  exert  such  influence.  A  fit  of  gout, 
or  the  development  of  acute  rheumatism,  seem  on  derivative  principles  to 
lessen  this  nerve-pain,  and  diminish  in  or  remove  from  the  organism  those 
conditions  of  irritation  which  particularly  affect  the  cerebro-spinal  and 
ganglionic  nerves.  It  sometimes  happens,  when  the  aflection  comes  on 
in  females,  that  a  very  large  secretion  of  pale  or  almost  colorless  urine  is 
at  once  succeeded  by  the  mitigation  of  the  attack.  In  some  cases  the 
abdominal  and  thoracic  muscles  are  spasmodically  contracted;  there  are 
rigidity  of  the  recti  and  a  loss  of  motor  power  in  the  intercostals,  the 
chest  is  fixed,  and  the  breathing  is  oppressed.  When  the  seizures  become 
repeated,  they  are  liable  to  be  characterized  by  greater  severity,  the  exal- 
tation of  the  nervous  sensibility  doubtless  becoming  augmented  by  con- 
tinued irritation.  The  duration  of  the  symptoms  is  always  most  uncer- 
tain, as  much  will  depend  upon  the  kind  of  fundamental  cause  by  which 
they  are  produced:  it  may,  however,  be  regarded  as  the  most  usual  fact 
that  the  more  severe  the  fit  the  shorter  will  be  its  continuance.  In  chil- 
dren spasmodic  pain  of  the  bowels  is  soon  productive  of  disorder  in  the 
digestive  functions,  and  irritation  in  the  alimentary  tube  is  soon  followed 
by  the  ordinary  conditions  which  characterize  infantile  convulsions.  Ac- 
cording to  M.  Billard,  the  child  cries  suddenly  and  loudly,  the  face  is 
contracted,  the  limbs  are  stiffened,  the  belly  is  tender  to  the  touch,  there 
is  tympanitic  distention,  and  the  attack  is  often  relieved  by  the  expulsion 
of  large  quantities  of  gas  per  anum.^  The  alvine  evacuations  are  gener- 
ally suspended,  and  frequently  there  are  vomiting  and  carpo-pedal  con- 
tractions; in  young  infants  there  is  tossing  of  the  arms,  the  legs  are 
drawn  up  to  the  abdomen,  and  often  in  the  course  of  time  green  and  of- 
fensive stools  are  voided.  Frequently  upon  investigation  it  will  be  found 
that  the  mother's  milk,  or  the  artificial  food  which  has  been  given,  is  the 
cause. 

Pathology. — In  the  discussion  of  this  part  of  the  subject,  those  mor- 
bid conditions  may  first  be  noticed  that  consist  of  impairment  of  the  func- 
tions of  the  bowels,  which  are  characterized  by  alteration  of  sensibility, 
and  which  are  often  in  association  with  a  lowered  state  of  vitality  in  the 
economy;  but,  as  in  all  functional  affections,  the  real  origin  of  the  com- 
plaint cannot  always  be  detected,  and  remains  an  uncertain  inference.  It 
frequently  happens  that  when  some  irritation  of  the  mucous  surface  of  the 
bowels  is  the  cause,  gases  become  generated,  and  painful  dilatation  of  some 
part  or  parts  of  the  tube  is  the  consequence.  It  is  probable  that  a  great 
portion  of  the  gas  is  secreted  from  the  blood,  for  the  flatus  is  often  pro- 
duced too  quickly  and  in  too  great  abundance  for  the  presumption  that 
it  comes  entirely  from  the  decomposition  of  the  ingesta.  By  this  distention 
of  any  particular  section  of  the  gut  there  is  loss  of  tone,  the  contractile 
power  of  the  muscular  coat  may  be  almost  or  entirely  abolished,  and  the 
pressure  on  the  sensitive  nervous  fibriles  occasioned  by  such  dilatation  will 
well  account  for  the  complaint,  because  there  may  be  asthenia  of  this 
part  of  the  ganglial  system  in  accompaniment  with  morbid  exaltation  of 
sensibility.     This  irritation  of  the  peripheral  nerves,  caused  by  harmful 

'  Traitc  des  Maladies  dos  Efffans  nouveaux-nes  et  a  la  Mamelle.     8vo.  Paris,  1828. 


6  DISEASES   OF   THE   INTESTINES   AND   PERITONEUM. 

ingesta,  concretions,  vitiated  secretions,  and  the  like,  affects  not  only  the 
intestines  themselves,  but  other  organs  also;  and  thus  it  is  that  the  lieart 
and  diaphrap^m  are  functionally  influenced,  and  hence  the  depressed  circu- 
lation and  difficult  respiratory  movement  so  commonly  witnessed  in  the 
more  violent  examples  of  the  ailment.  As  pain  is  often  to  be  regarded 
as  the  prominent  expression  of  some  malady  pervading  the  entire  system, 
and  as  the  functions  of  any  organ  may  be  thus  disturbed,  it  not  infre- 
quently occurs  that  one  or  other  of  the  viscera  is  the  seat  of  such  disease; 
and  thus  it  is  that  in  contamination  of  the  blood  spasmodic  or  neuralgic 
pain  of  the  intestines  may  result.  In  saturnine  poisoning  there  is  ample 
illustration  of  this  fact;  the  poison  is  transferred  into  the  circulation,  the 
secretions  are  arrested,  and  fits  of  agonizing  pain  are  felt  in  the  bowels: 
and  so  it  doubtless  occurs  in  those  dycrasial  affections  in  which  the 
fluids  of  the  body  are  degraded  by  changes  more  occult,  and  by  the  opera- 
tion of  agents  less  pKainly  comprehended.  In  gout  and  rheumatism,  and 
in  Bright's  disease,  the  cerebro-spinal  and  organic  centres  are  secondarily 
influenced  through  debasement  of  the  blood.  When  gout  is  retrocedent 
or  rheumatism  suppressed,  tlieir  peccant  materials  are  revulsed  upon  and 
irritate  some  of  the  internal  organs;  and  in  Bright's  disease,  when  tlie 
urinary  excreta  are  imperfectly  eliminated,  the  disturbance  of  the  nervous 
system  is  exemplified  not  only  in  the  exaltations  of  sensibility  in  the  vis- 
cera— neuralgia — but  in  perverted  motor  function,  as  evidenced  in  the 
reflex  action  of  vomiting  and  diarrhoea.  In  simple  asthenia,  when  there 
is  excess  of  emotional  and  other  motility,  as  in  hysterical  females,  the 
kinds  of  pain  in  question  are  readily  developed;  and  if  it  cannot  be  said 
that  structural  changes  do  not  exist,  at  least  they  cannot  be  indicated. 

When  organic  disease  in  some  cogni:iable  form  does  constitute  the 
cause  of  Enteralgia,  the  examples  may  be  most  varied  in  their  locality, 
degree  of  objective  symptoms,  and  the  kind  and  amount  of  their  struc- 
tural alteration.  When  the  primary  lesion  is  in  the  cerebro-spinal  axis, 
chemical,  physical,  and  mechanical  aids  to  diagnosis  are  of  no  avail,  and 
we  are  compelled  to  rely  upon  analogies  and  subjective  representations.' 
One  of  the  most  frequent  pathologic  conditions  is  that  of  hypera?mia, 
which  produces  irritation  and  reflex  phenomena.  According  to  Brown- 
Scquard,*  when  the  afHux  of  blood  or  other  morbid  change  is  at  the  pos- 
terior parts  of  the  cerebro-spinal  axis,  hypennesthesia  is  the  common 
result;  and  it  would  seem  that  interruption  of  continuity  of  the  vaso- 
motor nerves  is  the  fundamental  cause  of  vascular  dilatations.  In  spinal 
irritation  and  hysteria  reflex  visceral  pains  thus  doubtless  arise;  and  it 
may  truly  be  affirmed  that  the  causes  of  spasmodic  and  neuralgic  pains 
are  more  commonly  central  than  peripheral — in  figurative  language,  they 
are  more  frequently  referable  to  the  battery  than  the  conducting  wires. 
In  positive  inflammation  of  the  cerebral  and  spinal  tissues  abnormities  of 
function  must  necessarily  arise.  The  nerves  are  seldom  diseased.  Albers 
and  West  in  only  exceptional  cases  found  the  vagi  morbid  on  inspections 
after  whooping-cough.  Bichat*  repeatedly  examined  the  nerves  in  dis- 
eases of  the  viscera  without  discovering  pathologic  change.  But  accord- 
ing to  the  testimony  of  various  writers,  and  from  my  own  observations, 
the  nerves  are  sometimes  inflamed,  and  are  subject  to  other  morbid  altera- 
tions.    The  neurilemma  is   the   part  most   prone  to  inflammation,  and 

'  Sieveking,  Manual  of  Patholog.  Anat.  p.  211. 
*  Lectures  on  the  Central  Nervous  System,  p.  205 . 
'  Anatomie  gdnorole,  L  225. 


ENTERALGIA.  7 

Craigie  '  asserts  that  such  condition  is  a  common  cause  of  neuralgic  pain. 
In  tetanus  and  sciatica  the  entire  nerve  has  been  seen  red  and  swollen. 
The  sympathetic  ganglia  are  sometimes  diseased;  there  may  be  vascular- 
ity of  the  cellular  tissue  interposed  between  the  elements  of  the  ganglia, 
and  the  ganglionic  substance  has  been  seen  enlarged  and  indurated.  It  is 
also  highly  presumptive  that  there  may  be  molecular  change  in  the  contents 
of  the  ganglionic  corpuscles.  Neuromatus  formations  may  be  the  cause  of 
Enteralgia,  As  I  have  already  remarked,  the  more  common  and  obvious 
conditions  of  visceral  disease  may  produce  enteralgic  pain,  such  as  thick- 
ening of  the  inner  tunics  of  the  bowel,  whereby  impediment  is  given  to 
the  contents  of  the  tube;  an  ancient  band  of  lymph  giving  rise  to  con- 
striction ;  or  by  some  abnormal  growth  pressing  upon  the  gut.  And  in 
the  various  organic  affections  to  which  the  solid  organs  are  liable,  re- 
flected enteralgic  pain  is  no  unusual  result.  In  diseases  of  the  urinary 
and  generative  organs  of  both  sexes  the  kinds  of  abdominal  pain  now 
spoken  of  not  unusually  supervene.  Ulceration  of  the  uterus  and  impac- 
tion of  the  ureters  sometimes  cause  Enteralgia. 

Diagnosis. — The  diagnostic  indications  of  Enteralgia  are  sudden, 
darting,  plunging,  or  twisting  pains,  which  come  on  paroxysmally,  the 
attacks  varying  in  their  degree  of  severity  and  in  their  duration.  The 
intervals  between  the  seizures  may  be  almost  or  altogether  free  from  suf- 
fering. The  pulse  remains  unaltered,  the  surface  is  cool,  and  the  facial 
expression  is  that  of  pallor  and  pain.  There  is  moist  tongue,  no  thirst, 
the  bowels  are  confined,  and  flatulent  distention  is  the  common  accompani- 
ment. Pressure  on  the  abdomen  relieves  rather  than  augments  the  pain, 
and  it  is  not  unusual  for  the  patient  to  press  his  hands  on  his  belly  during 
the  paroxysm  as  a  means  of  affording  relief.  The  expulsion  of  gases 
from  the  large  bowels  gives  immediate  ease;  and  sometimes  the  advent  of 
diarrhoea  at  once  cuts  short  the  complaint.  In  inflammation  of  the  bow- 
els pressure  confers  pain,  the  skin  is  hot  and  dry,  the  pulse  quick,  the 
face  flushed,  the  secretions  and  excretions  are  diminished,  the  patient 
cannot  turn  and  twist  about  in  bed  as  he  can  in  Enteralgia,  and  the 
ol)jective  symptoms  of  symptomatic  fever  are  more  or  less  proclaimed. 
In  inflammation  the  pain  is  confined  to  one  particular  part  of  the  abdo- 
men, and  only  gradually  becomes  diffused.  In  Enteralgia  it  shifts  about 
with  great  celerity.  In  ileus  there  is  vomiting,  and  at  length  of  fascal  mat- 
ters; a  lump  can  often  be  felt,  and  the  suffering,  as  in  inflammation,  does 
not  intermit.  When  this  neuralgia  of  the  bowels  is  from  impaction  of 
f<eces,  palpation  and  percussion  will  be  our  guides;  if  from  concretions 
or  mechanical  obstructions,  the  history  of  the  case  and  collateral  circum- 
stances will  conduct  to  a  right  decision;  and  if  from  irritative  secretions,  a 
flux  generally  supervenes.  If  reflected  by  distal  disease,  as  in  hepatic, 
splenic,  and  renal  ailments,  those  organs  should  be  carefully  examined. 
In  neuralgia  the  pain  radiates  round  to  the  back,  generally  at  one  side. 
In  the  passage  of  renal  calculus  the  pain  is  in  one  side;  it  darts  down 
towards  the  pubes  and  thigh,  and  in  the  male  there  is  retraction  of  the 
testicle.  In  rheumatism  of  the  abdominal  muscles  the  disease  pervades 
some  other  part.  In  hysteria  the  spine  should  be  examined;  and  when 
from  this  cause,  often  a  copious  discharge  of  colorless  urine  will  give  relief. 
In  lead-poisoning  there  will  mostly  be  dropping  of  the  wrists,  and  the 
blue  line  on  the  gums. 

Treatment. — The  remedies  first  indicated  are  those  which  are  most 

*  Pathological  Anatomy,  2d  edit.  p.  380. 


8  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

likely  to  abridge  and  mitigate  the  sufferings  of  the  paroxysm;  and  with 
this  view  antispasmodics  and  anodynes  may  be  prescribed,  such  as  opium, 
chloric  aether,  henbane,  conium,  camphor,  ammonia,  and  similar  agents. 
At  the  same  time  hot  fomentations,  sinapisms,  terebinthinate  epithems, 
or  stimulating  and  rubefacient  liniments,  may  be  employed.  The  surface 
should  be  kept  warm  and  diaphoresis  promoted,  which  can  be  best  accom- 
plished by  the  patient  first  putting  his  feet  and  legs  into  hot  mustard  and 
water,  and  then  going  to  bed.  The  warm  bath  and  sedative  enemata  are 
excellent  auxiliaries.  Sometimes  anodyne  embrocations,  addressed  to  the 
spine,  do  much  good.  In  the  more  chronic  neuralgic  affections,  I  have 
long  been  in  the  habit  of  prescribing  a  liniment  composed  of  laudanum, 
chloroform,  the  extract  of  belladonna,  and  the  linimentum  camphorae. 
The  bowels  should  afterwards  be  cleared  out  by  mild  laxatives,  such  as 
castor-oil,  the  compound  rhubarb  pill,  extract  of  colocynth  in  combina- 
tion with  extract  of  henbane,  or  the  galbanum  pill,  or  the  confection  of 
senna.  When  we  believe  the  fundamental  cause  to  reside  in  the  solid 
viscera,  or  in  the  cerebro-spinal  axis  or  ganglionic  centres,  our  measures 
should  then  be  addressed  to  such  parts,  and  our  aim  be  to  lessen  the  gen- 
eral morbid  excitability  of  the  nervous  system. 


ENTERITIS. 

By  John  Sybb  Bbistowe,  M.D.,  F.R.C.P. 


The  term  Enteritis,  signifying  inflammation  of  the  bowels,  is  of  an- 
cient date,  and  from  the  earliest  times  until  now  of  more  or  less  loose 
and  various  application.  It  has  often  been  applied  to  a  certain  group  of 
symptoms  irrespective  of  the  conditions  under  which  they  may  arise,  and 
irrespective  even  of  the  presence  or  absence  of  actual  inflammation,  as 
for  instance  to  strangulated  hernia,  intestinal  stricture,  and  other  forms 
of  obstruction  of  the  bovvels;  and  again  the  word  has  often  been  made  to 
include  various  specific  forms  of  disease  attended  with  specific  intestinal 
lesions,  such  for  example  as  enteric  fever,  tuberculosis,  and  cancerous  in- 
filtration. It  is  intended  in  the  present  article  to  treat  of  Enteritis, 
according  to  its  real  meaning,  as  a  simple  inflammatory  affection;  and  to 
eliminate  from  the  subject,  as  far  as  possible,  all  reference  to  the  diseases 
with  which  it  may  be  confounded  or  on  which  it  may  supervene. 

I.  As  AFFECTING  THE  Serous  AND  MuscuLAB  CoATS. — The  intestinal 
tunics  are  all  of  them  liable  to  inflammation  either  separately  or  in  com- 
bination: and  the  inflammatory  process,  as  it  occurs  in  each,  has  a  ten- 
dency to  present  characteristic  peculiarities,  and  to  be  associated  with 
special  symptoms.  Inflammation  of  the  serous  coat  is  of  frequent  occur- 
rence as  a  part  of  general  peritonitis,  a  disease  the  morbid  anatomy  and 
symptoms  of  which  are  subsequently  described;  but,  as  in  the  analogous 
cases  afforded  by  the  pleurne  and  pericardium,  inflammation  commencing 
liere  spreads  rarely,  or  with  difficulty  and  late,  to  the  subjacent  tissues; 
and  hence  peritonitis  may  be  considered  practically  to  be  as  distinct  from 
true  inflammation  of  the  bowels,  as  pleurisy  is  from  pneumonia,  or  peri- 
carditis from  inflammation  of  the  heart.  Nevertheless  inflammation 
beginning  at  the  peritoneal  surface  does  occasionally  invade  the  whole 
thickness  of  the  intestinal  walls;  and  still  more  frequently,  just  as  pneu- 
monia induces  inflammation  in  the  overlying  tract  of  pleura,  inflammation 
of  the  deeper  tissues  of  the  bowel  leads  to  circumscribed  inflammation 
of  the  investing  peritoneum,  and  to  the  superaddition  of  peritonitic 
symptoms  to  symptoms  previously  existing.  The  structures  lying  be- 
tween the  serous  and  mucous  tunics,  namely,  the  muscular  laminne  with 
their  associated  neiwous  plexuses  and  connective  tissue,  are  rarely  the 
primary  seat  of  inflammation;  occasionally,  it  is  true,  in  pyaemia  and 
under  other  exceptional  conditions,  an  abscess  forms  in  them;  but  they 
are  more  frequently  involved  in  the  extension  of  peritoneal  inflammation; 
and  still  more  frequently  they  become  inflamed  either  by  the  spread  of 
inflammation  from  an  inflamed  mucous  membrane,  or  in  consequence  of 
its  simultaneous  origin  in  the  several  intestinal  tunics.  Inflammation  and 
its  results  here,  in  their  slighter  forms,  scarcely  reveal  themselves  to  ordi- 


10  DISEASES   OF  THE  INTESTINES   AND   PERITONEUJI. 

nary  post-mortem  examination,  but  when  more  pronounced,  are  mani 
fested  anatomically  by  congestion  and  effusion  of  serum,  lymph,  pus,  or 
blood.     The  symptoms  which  they  induce  are  in  the  first  instance  prob- 
ably spasmodic  contraction  of  the  muscular  fibres,  subsequently  loss  of 
power  or  complete  paralysis. 

II.  As  AFFKCTixG  THE  Mucous  Membrane. — Inflammation  as  a  pri- 
mary and  characteristic  affection  occurs  far  more  frequently  in  the  mucous 
membrane  than  in  the  coats  external  to  it;  and  it  occurs  here  in  forms 
which  vary  considerably  according  to  its  cause,  the  constitutional  condi- 
tions under  which  it  arises  or  with  which  it  is  associated,  and  its  degree 
of  intensity. 

(a)  Catarrhctl  Inflammation. — The  slightest  and  simplest  form  of 
inflammation  is  usually  termed  catarrhal.  This  may  be  produced  by  the 
local  action  of  irritating  ingesta,  or  by  the  influence  of  those  external 
conditions  which  are  known  to  be  the  agents  in  setting  up  the  same  kind 
of  inflammation  in  other  parts;  and  it  is  believed  by  some  to  attend  gen- 
erally scarlatina  and  other  specific  fevers.'  Young  children,  particularly 
during  the  period  of  teething,  seem  specially  liable  to  it.  It  is  character- 
ized by  congestion,  tumefaction,  softening  and  dryness  of  the  mucous 
membrane,  followed  speedily  by  the  secretion,  often  in  considerable  abun- 
dance, of  mucus,  which  is  ropy  or  watery,  irritating,  and  sometimes  mixed 
with  blood.  It  sometimes  affects  the  lower  bowel  only,  producing  mild 
dysenteric  symptoms;  but  frequently  it  commences  in  the  upper  bowel, 
or  in  the  stomach,  and  spreading  thence  downwards  gradually  traverses 
the  whole  of  the  intestinal  canal,  causing  in  its  progress  more  or  less  un- 
easiness, aching  and  griping,  attended  frequently  with  nausea  and  sick- 
ness while  it  is  still  high  up,  with  diarrhrea  and  expulsive  pains  and 
efforts  when  it  reaches  the  large  intestine.  The  tongue  is  generally  more 
or  less  furred  and  diy,  the  breath  offensive,  and  the  appetite  impaired; 
but  these  symptoms  vary,  and  are  often  absent,  especially  when  the  large 
intestine  alone  is  affected.  Some  degree  of  general  febrile  disturbance, 
indicated  by  heat  and  dryness  of  skin  with  sense  of  chilliness,  increased 
frequency  of  pulse,  lassitude  an'd  headache,  is  usually  attendant  on  the 
local  disorder.  In  children,  in  whom  inflammatory  affection  of  the  gastro- 
intestinal mucous  membrane  is  sometimes  associated  with  aphtha,  the 
disease  not  infrequently  produces  serious  results  and  death,  either  from 
the  debility  which  follows  persistent  diarrhoea  and  vomiting,  or  from  the 
supervention  of  cerebral  complications,  such  as  convulsions  or  coma. 
There  can  be  no  doubt  that  a  large  number  of  cases  of  gastro-intestinaj 
disturbance  and  of  diarrhoea  are  due  to  catarrhal  inflammation;  yet  the 
existence  of  such  inflammation  is  more  a  matter  of  inference  from  symp- 
toms than  of  direct  observation  upon  the  condition  of  the  mucous  mem- 
brane. For  the  latter  can  only  be  examined  after  death,  at  which  time 
congestion  and  other  indications  of  superficial  and  slight  inflammation 
have  for  the  most  part  disappeared,  or  are  lost  in  post-mortem  changes. 

(h)  Croupous  Inflammation. — The  designation  "croupous"  (diph- 
theritic or  membranous)  inflammation  is  given  to  those  cases  in  which 
the  mucous  surface  becomes  covered  to  a  greater  or  loss  extent  with  a 
more  or  less  adherent  membranous  film  consisting  of  corpuscular  elements 
cemented  together  by  a  coagulable  exudation,  and  prolonged  for  the 
most  part  by  rootlets,  from  its  under-surface  into  the  Lieberkuhnian  folli- 

'  See   Dr.   Fenwick  on   "The   Gonditioa  of   Stomach  and  Intestines   in   Scaiiet 
Fevsr,"  Med,  Chir.  Trans,  vol.  xlvii. 


ENTERITIS.  11 

cles.  This  affection,  which  is  far  from  uncommon,  may  sometimes  doubt- 
less be  regarded  as  the  expression  of  some  specific  form  of  inflammation; 
certainly  many  believe  (and  I  am  one  of  them)  that  it  is  a  common  fea- 
ture in  the  early  stage  of  dysentery;  at  the  same  time  it  frequently  occurs 
quite  independently  of  all  infectious  or  malarious  influence.  It  undoubt- 
edly indicates  greater  intensity  of  inflammation  than  mere  catarrhal  in- 
flammation ;  there  is  generally  much  greater  congestion  and  thickening 
of  mucous  membrane,  and  not  unfrequently  hemorrhage,  suppuration,  or 
gangrene.  Croupous  inflammation  is  often  met  with  in  the  large  intes- 
tine in  scattered  patches,  which  are  sometimes  linear,  sometimes  irregu- 
larly polygonal  or  stellate,  and  occupy  for  the  most  part  the  prominent 
ridges  of  the  mucous  membrane,  more  especially  the  edges  of  the  inter- 
saccular  constrictions.  In  some  cases,  still  chiefly  occupying  the  more 
prominent  parts,  it  forms  a  coarse,  irregular  network  extending  over  large 
tracts  of  surface;  in  other  cases  it  forms  uniform  patches  of  considerable 
extent.  It  is  less  common  in  the  small  intestines,  but  may  be  found  in 
them  affecting  the  free  edges  of  the  valvulre  conniventes,  or  spread  over 
a  large  area.  It  is  sometimes  met  with  on  the  surface  of  tracts  of  cancer- 
ous infiltration  which  are  on  the  eve  of  ulcerating.  It  may  be  added 
here  that  cases  sometimes  come  under  observation  in  which  patients  pass 
per  amim  shreds  of  false  membrane,  or  even  membranous  casts  of  the 
bowel,  of  soft  texture,  various  thickness,  and  of  a  dirty  greenish  or 
brownish  hue.  This  discharge  is  generally,  if  not  always,  a  consequence 
of  dysenteric  ulceration.  The  symptoms  which  attend  croupous  inflam- 
mation are  not  special;  they  vary,  according  to  circumstances,  on  the  one 
hand  between  those  of  diarrhoea  and  dysentery,  and  on  the  other  hand 
between  those  of  mere  colic  and  of  typical  enteritis.  The  patchy  form, 
indeed,  so  common  in  the  large  intestine,  is  often  overlooked  during  life, 
from  the  fact  that  it  occurs  as  a  complication  in  the  later  stages  of  many 
grave  disorders,  as,  for  example,  acute  pneumonia,  Bright's  disease,  cir- 
rhosis of  the  liver,  and  cerebral  affections. 

(c)  Chronic  Inflammation  and  Degeneration. — Both  catarrhal  and 
croupous  inflammations,  in  their  slighter  degrees,  generally,  and  for  the 
most  part  speedily,  undergo  resolution.  Sometimes,  however,  they  end 
in  ulceration;  an  event  which,  with  its  consequences,  is  fully  considered 
further  on.  And  sometimes  they  lead  to  persistent  modifications  of  the 
mucous  membrane  which  are  often  included  in  the  term  "  chronic  inflam- 
mation." These  consist  generally  in  slight  condensation  and  hardening 
of  the  mucous  tissue,  more  or  less  distinct  congestion,  or  black  pigmentary 
deposit  in  the  villi  and  interfollicular  spaces,  some  degree  of  atrophy  of 
the  Lieberkuhnian  follicles,  and  granular  or  fatty  degeneration  of  their 
epithelial  contents,  together  with  an  analogous  condition,  more  or  less 
pronounced,  of  the  epithelium  of  the  mucous  surface  generally.  The  soli- 
tary and  agminated  glands  are  sometimes  atrophied,  sometimes  larger  and 
more  obvious  than  natural.  The  changes  indeed  are  chiefly  changes  of 
degeneration;  and  in  that  sense,  as  probably  also  clinically,  are  related  to 
the  lardaceous  degeneration  which  occasionally  happens  in  persons  labor- 
ing under  chronic  tuberculosis,  bone  disease  attended  with  suppuration, 
and  secondary  syphilis.'  Lardaceous  degeneration  occurs  later  in  the 
bowel  than  in  the  liver,  spleen,  and  kidneys;  it  is  found  chiefly  in  the 
lower  part  of  the  ileum  and  in  the  large  intestine;  it  affects  in  the  first 

'  See  a  good  account  of  lardaceous  degeneration,  JI.  Hayem.  quoted  in  New  Syden- 
ham Society's  Biennial  Retrospect  of  Medicine  and  Surgery,  for  1865-6,  p.  176. 


12  DISEASES    OF   THE    INTESTINES   AND    PERITONEUM. 

instance  the  small  arteries  and  capillaries  around,  and  in  the  solitary  and 
agminated  glands,  which  bodies  become  swollen;  and  then  gradually  tends 
to  involve  the  whole  thickness  of  the  intestinal  wall,  the  muscular  fibres 
and  other  tissues  becoming'  finally  infiltrated.  The  bowel  thus  becomes 
thickened,  and  at  the  same  time  harder  than  natural;  and  often  in  the 
later  stages  erosion  of  the  affected  glands  occurs,  leading  in  Peyer's  patches 
to  a  reticulated  condition  of  surface.  The  above  chronic  affections  of  the 
mucous  membrane  are  generally  associated  with  diseased  conditions  of 
other  organs,  to  which  indeed  they  are  secondary;  and  not  infrequently 
the  stomach  is  at  the  same  tin^e  the  seat  of  some  chronic  morbid  process. 
The  presence  of  these  complications,  and  the  fact  that  clinically  ulceration 
of  the  bowels,  together  with  tubercular  and  other  morbid  processes,  passes 
in  a  large  number  of  cases  for  chronic  inflammation,  render  it  difficult  to 
isolate  the  clinical  phenomena  due  specially  to  the  bowel  affections  now 
under  consideration.  They  doubtless  vary  greatly;  but  may  be  briefly 
summarized  as  combining  in  various  proportions,  both  relatively  and  posi- 
tively, imperfect  digestion  of  the  alimentary  matters  received  into  the  in- 
testine, excessive  secretion  of  more  or  less  watery  mucus,  increased  peri- 
staltic movements  with  griping  pains,  looseness  of  bowels  with  discharge 
of  watery,  or  yeasty,  or  otherwise  unhealthy  -and  offensive  evacuations, 
and  innutrition  from  the  imperfect  absorption  of  food. 

III.    As    AFFECTIXG   THE  WHOLE    THICKNESS   OF  THE    BoWEL. By  tho 

older  writers  generally,  and  for  the  most  part  also  by  those  of  more  recent 
times,  the  simple  unqualified  name  "Enteritis"  has  been  used  to  signify 
a  special  group  of  symptoms  associated  with  the  presence  of  a  more  or  less 
extensive  tract  of  intensely  inflamed  bowel.  The  affection  here  referred 
to  is  termed  by  Cullen  phlegmonous  enteritis,  in  contradistinction  to  the 
milder  varieties  of  inflammation,  affecting  the  mucous  membrane  only, 
which  he  included  under  the  name  of  erythematous  enteritis. 

The  symptoms  which  are  supposed  to  characterize  this  form  of  enteritis 
may  creep  on  insidiously  or  show  themselves  in  sudden  intensity,  and  con- 
sist mainly,  in  the  earlier  stages,  in  more  or  less  severe  abdominal  pain 
(resembling  in  its  character  and  in  its  increase  by  pressure  and  by  move- 
ment the  pain  of  peritonitis,  but  differing  from  it  in  being  associated  with 
colic),  obstinate  constipation,  nausea  and  vomiting  (occurring  both  after 
and  independently  of  the  ingestion  of  food),  and  marked  febrile  disturb- 
ance; and  subsequently  (supposing  the  case  to  be  going  on  unfavorably) 
in  the  gradual  supervention  of  tympanitis,  attended,  for  the  most  part, 
with  diminution  or  even  total  cessation  of  abdominal  pain  and  tenderness, 
with  still  persistent  constipation  and  vomiting  (the  vomited  matters  becom- 
ing opaque,  brown,  and  foetid,  if  not  actually  fsipcal),  with  hiccough  fre- 
quently, and  with  collapse  (indicated  by  extreme  feebleness  of  pulse,  cold- 
ness and  dampness  of  the  surface,  especially  in  the  extremities),  and  finally 
death  from  asthenia.  The  morbid  changes  which  may  be  looked  for  after 
death  are  such  as  are  produced  by  intense  inflammation  of  a  limited  tract 
of  intestine.  The  affected  part,  which  is  mostly  in  the  small  intestine, 
and  which  may  vary  in  length  from  an  inch  or  two  to  one  or  two  feet  or 
more,  is  as  a  rule  much  dilated;  its  serous  surface  presents  a  general  dusky 
red,  or  slate,  or  purplish-black  color,  due  to  the  condition  of  the  parts 
internal  to  it;  it  is  marked,  too,  by  lines  or  patches  of  more  or  less  intense 
superficial  congestion,  may  present  blotches  of  sub-serous  extravasation, 
and  is  often  covered  more  or  less  with  adherent  lymph;  its  mucous  and 
sub-mucous  tissues  are  mostly  somewhat  thickened  and  softened,  some- 
times only  moderately  congested,  but  presenting  spots  and  streaks  of  ex- 


EirrERiTis.  13 

travasation,  sometimes  black  from  combined  congestion  and  extravasation, 
sometimes  pale  and  infiltrated  with  lymph  or  pus,  sometimes  distinctly 
gangrenous;  and  its  middle  coat,  sharing  in  these  changes,  is  also  morn^ 
or  less  swollen  and  soft,  and  congested  or  oedematous,  or  the  seat  of  some 
form  of  inflammatory  exudation.  The  inflamed  tract  usually  presents 
fairly  well-defined  limits,  terminating  abruptly  below  in  pale  and  healthy 
but  contracted  and  nearly  empty  bowel,  above  in  bowel  which  may  also 
be  healthy,  but  is  dilated  like  the  diseased  portion  and  filled  like  it  with 
faecal  contents.  The  diseased  intestine  contains  frequently  in  addition  to 
simpl}'  faecal  matters  more  or  less  sanguineous  exudation;  and  traces  of 
the  same  exudation  may  often  be  discovered  in  the  contracted  bowel 
below. 

Now,  the  above  phenomena  are  by  no  means  infrequently  met  with ; 
they  are  the  common  accompaniments  of  strangulated  hernia  and  of  in- 
tussusception; they  are  present  in  those  cases  in  which,  as  is  supposed, 
the  sigmoid  flexure  or  some  other  loop  of  bowel  becomes  twisted  on  itself 
and  thus  strangulated;  they  supervene  whenever  a  gall-stone  or  other  foreign 
body  of  sufficient  size  becomes  fixed  in  its  passage  along  the  intestine; 
they  occur  sometimes  also  as  a  late  event  in  stricture,  or  in  those  cases  in 
which  the  bowel  becomes  constricted  by  bands  of  lymph;  they  are  some- 
times developed  as  a  result  of  the  extension  of  inflammation,  either  from 
peritoneum  or  from  an  intestinal  ulcer;  and  very  rarely  indeed  they 
originate  idiopathically,  that  is  to  say  from  such  general  causes  as  produce 
idiopathic  peritonitis,  idiopathic  pneumonia,  and  the  like.  Enteritis, 
therefore,  is  a  disease  which  is  almost  always  complicated  with  some  other 
grave  lesion,  on  which  indeed  it  depends,  and  which  modifies  alike  its 
symptoms  and  its  progress. 

But  evien  in  the  uncomplicated  form  of  the  disease,  which  is  alone  now 
under  consideration,  the  symptoms  are  liable  to  considerable  variety;  the 
variations  depending  mainly  on  the  degree  of  intensity  of  the  inflammation 
and  its  extent,  and  on  the  situation  of  the  affected  portion  of  bowel. 
Indeed,  the  two  principal  factors  in  producing  the  characteristic  symp- 
toms of  enteritis  are  inflammation,  on  which  depend  the  various  febrile 
phenomena,  and  paralysis  of  the  inflamed  portion  of  bowel,  which  permits 
of  its  passive  dilatation  by  the  accumulation  of  contents,  opposes  a  more 
or  less  complete  bar  to  their  transit,  and  thus  induces  on  the  one  hand 
constipation,  on  the  other  vomiting. 

The  most  important  practical  distinction  between  colic  and  enteritis 
is,  according  to  most  authors,  the  absence  of  febrile  symptoms  in  the 
former  disease,  their  presence  in  the  latter.  And  no  doubt  in  most  cases 
of  enteritis  febrile  symptoms  manifest  themselves  in  a  marked  degree,  at 
least  in  the  earlier  stages  of  the  malady.  Heat  of  skin,  rigors,  quickness 
and  hardness  of  pulse,  not  infrequently  mark  the  onset  of  the  attack;  but 
it  is  a  mistake  to  suppose  they  are  always  present,  or  at  all  events  readily 
perceptible,  for  in  many  cases  no  rigors  are  experienced,  and  in  some 
there  is  little  or  no  acceleration  of  pulse  until  towards  the  close  of  life, 
and  no  more  heat  of  surface  than  may  attend,  and  often  does  attend,  the 
gripings  of  ordinary  colic.  There  is  mostly  some  dryness  and  clamminess 
of  mouth,  if  not  absolute  thirst;  and  the  tongue,  which  is  occasionally 
pretty  clean  at  the  beginning,  becomes  generally  soon  thickly  coated  and 
ultimately  dry.  Another  feature  of  enteritis  upon  which  much  reliance  is 
placed  is  the  association  of  the  abdominal  pain  and  tenderness  of  peritonitis 
with  the  tormina  of  colic.  Pain  and  tenderness  are  certainly  present  in 
most  cases,  at  least  in  the  beginning,  and  in  dependence  upon  them  the 


14  DISEASES    OF   THE   INTESTINES    AND   PERITONEUJI. 

dorsal  decubitus,  so  characteristic  of  peritoneal  inflammation.  But  these 
symptoms  vary  greatly;  sometimes  they  are  intensely  severe,  sometimes 
tliey  are  from  first  to  last  scarcely  appreciable,  and  generally  they  subside 
in  the  progress  of  the  case.  It  can  readily  be  understood  that  when  the 
peritoneal  surface  is  largely  involved,  the  pain  and  tenderness  will  gener- 
ally be  proportionably  severe;  that  when  an  extensive  length  of  bowel  is 
affected,  there  will  be  correspondingly  extensive  uneasiness  and  tenderness; 
and  that  when,  as  sometimes  happens,  the  serous  surface  is  not  inflamed, 
or  when  the  affected  portion  of  bowel  is  small,  the  pain  and  tenderness 
may  be  not  only  limited  in  extent,  but  no  greater  than  one  finds  them  in 
colic  or  in  simple  ulceration  of  the  mucous  membrane.  It  is  worth  while 
to  remark,  that  limited  pain  and  tenderness  are  very  commonly  referred 
to  the  region  of  the  umbilicus.  Tormina  are  often  at  the  onset  very  ago- 
nizing, being  then  probably  due  in  some  measure  to  the  spasmodic  move- 
ments of  the  inflamed  bowel;  but  they  continue  even  after  paralysis  has 
become  established,  in  consequence  of  the  violent  but  ineffective  efforts 
of  the  bowel  above  the  seat  of  disease  to  overcome  the  impediment  which 
the  disease  produces.  But  tonnina  are  sometimes  scarcely  recognizable, 
and  frequently,  like  pain,  cease  comparatively  early.  Constipation  and 
vomiting  are  among  the  most  essential  symptoms  of  enteritis.  In  the 
•ancomplicated  affection  the  impediment  to  the  action  of  the  bowel  is  due 
simply  to  the  presence  of  a  paralyzed  and  inactive  zone  of  greater  or  less 
breadth  between  an  upper  and  a  lower  length  of  healthy  bowel;  it  is  no 
necessary  part  of  the  disease,  therefore,  that  the  outbreak  of  acute  symp- 
toms shall  have  been  preceded  by  constipation,  or  even  that  after  the  dis- 
ease has  become  established  the  portion  of  the  bowel  below  the  inflamed 
part  shall  not  empty  itself;  and,  it  may  be  added,  that  in  a  variable 
degree  the  contents  even  of  the  inflamed  gut  may  slip  or  be  squeezed 
onwards  into  the  healthy  tube  beyond,  and  that  even  calomel,  and  such 
other  purgatives  as  act  rather  through  the  system  than  directly,  may  pro- 
duce to  some  extent  their  characteristic  effects.  But  it  is  nevertheless  a 
fact  that  the  inflamed  bowel  is  really  a  substantial  impediment,  that  there 
is  therefore  during  the  progress  of  the  disease  marked  constipation,  and 
that  purgatives  as  a  rule  produce  no  purgative  effect.  Vomiting  may 
occur  in  colic,  in  diarrhcea,  in  simple  peritonitis,  and  in  many  other  con- 
ditions as  a  mere  sympathetic  affection;  and  sympathy  has  probably  some 
share  in  its  production  even  in  enteritis,  at  least  at  the  commencement. 
But  ultimately  the  vomiting  here  is  due  directly,  like  the  constipation,  to 
intestinal  obstruction.  In  the  first  instance,  no  matter  where  the  obstruc- 
tion or  what  the  immediate  cause  of  vomiting,  the'  vomited  matters  are 
merely  the  secretions  of  the  stomach  mixed  with  alimentary  substances; 
but  soon  bile  becomes  mixed  with  these;  and  before  long  glairy  mucus  and 
bile  alone  are  discharged.  Then  the  eructations  become  foetid;  and  soon 
the  fluid  brought  up  gets  turbid  and  brownish,  and  by  degrees  comes  to 
resemble  the  contents  of  the  lower  part  of  the  small  intestine,  but  it 
becomes  fcetid  also,  and  sometimes  much  more  foetid  than  the  contents  of 
a  healthy  bowel  ever  are,  the  foetor  being  caused  partly  by  decomposition 
of  the  faical  matters,  partly,  as  in  dysentery,  by  the  discharges  taking 
place  from  a  gangrenous  or  otherwise  diseased  mucous  surface.  This 
vomiting  of  the  contents  of  the  intestines  is,  as  Dr.  Brinton  has  well 
explained,  not  due  to  inversion  of  peristaltic  action;  but  is  the  result  of 
the  gradual  accumulation  of  matters  in  the  bowel  above  the  seat  of  dis- 
ease, of  their  mixture  gradually  effected  by  the  normally-directed  peri- 
staltic movements  of  tlie  bowel,  and  of  their  escape  into  the  stomach 


ENTERITIS.  15 

partly  by  simple  overflow,  induced  sometimes  by  mere  change  of  posture, 
partly  by  the  pressure  exerted  on  the  distended  bowel  by  the  surrounding 
viscera,  and  by  the  muscular  walls  of  the  abdomen.  The  foetid  matters 
which  thus  reach  the  stomach  often,  towards  the  close  of  life  particularly, 
escape  from  it  into  the  mouth  by  mere  regurgitation.  Tympanitis  is  prob- 
ably in  no  case  wholly  wanting;  in  an  early  stage  it  may  be,  and  perhaps 
usually  is,  absent  or  but  little  marked;  ere  long,  however,  the  abdomen 
begins  to  enlarge,  and  generally  as  the  case  progresses  becomes  greatly 
distended,  tense,  and  drum-like.  This  condition  is  of  course  mainly  due 
to  the  distention  by  fascal  contents  and  flatus  of  the  portion  of  intestinal 
tube  which  is  inflamed  and  of  that  which  is  above  it,  but  now  and  then  it 
is  connected  with  rupture  of  the  distended  intestine  and  escape  of  gas 
into  the  peritoneal  cavity — an  accident,  it  need  scarcely  be  said,  of  fatal 
augury.  The  pulse  at  the  beginning  is,  as  has  been  already  remarked, 
often  accelerated  and  hard,  but  it  varies  greatly  in  different  cases,  both 
in  frequency,  volume,  and  strength,  and  sometimes  retains  pretty  nearly 
its  ordinary  healthy  character  throughout  at  least  the  earlier  stages  of  the 
disease.  As  the  fatal  issue,  however,  approaches,  it  becomes  more  and 
more  feeble,  and  sometimes  at  length  wlaolly  imperceptible  at  the  wrist; 
it  generally  becomes  then  also  quicker,  sometimes  slower,  and  not  infre- 
quently irregular.  The  temperature  of  the  skin  is  usually  in  the  first 
instance  more  or  less  elevated,  and  its  surface  dry;  but  even  then  perspi- 
rations are  apt  to  break  out,  especially  during  the  paroxysms  of  colicky 
pain:  subsequently,  however,  the  temperature  falls,  the  extremities  and 
face  become  cold  and  pale,  or  livid,  with  sometimes  a  faint  tinge  of  jaun- 
dice, and  all  parts  of  the  surface  bathed  in  profuse  cold  perspiration. 
The  expression  of  the  patient  is  generally  indicative  of  anxiety  and  dis- 
tress, and  it  has  often  been  noted  that,  towards  the  close  of  life,  the  face 
becomes  pinched  and  shrivelled,  and  assumes  an  unnatural  aspect  of  old 
age.  He  generally  retains  his  senses  throughout  his  illness,  and  even  up 
to  the  moment  of  death:  but  this  event  is  often  preceded  by  a  period  of 
quiescence  or  lethargy,  and  occasionally  by  slight  rambling  and  almost 
complete  unconsciousness.  It  may  be  added  here,  that  there  is  generally 
in  enteritis  more  or  less  complete  suppression  of  urine,  a  phenomenon 
which  has  been  variously  interpreted,  but  which  is  probably  due,  as  Mr. 
Sedgwick'  argues,  to  the  influence  of  the  abdominal  sympathetic  system. 

Enteritis,  in  that  intense  form  of  it  which  has  been  now  described,  is 
undoubtedly  a  very  fatal,  and  indeed  very  rapidly  fatal,  malady.  It  is  so 
difficult,  however,  practically  to  isolate  the  comparatively  few  cases  in 
which  it  forms  the  primary  and  sole  disease  from  the  many  in  which  it 
supervenes  as  a  complication  of  some  pre-existing  graver  lesion,  that  the 
former  scarcely  admit  of  statistical  examination.  As  respects  the  dura- 
tion, however,  of  fatal  cases,  it  may  be  asserted  that  it  rarely  exceeds  a 
week,  and  that  it  may  be  as  short  as  twenty-four  or  thirty-six  hours. 

IV.  Treatment. — It  seems  scarcely  necessary  to  discuss  here  the 
treatment  of  simple  catarrhal  and  croupous  and  chronic  inflammation  of 
the  bowels;  these  inflammations,  indeed,  are  so  intimately  connected,  on 
the  one  hand  with  inflammatory  conditions  of  the  stomach,  on  the  other 
with  dysentery  and  diarrhoea,  which  have  all  been  elsewhere  described  at 
length,  that  the  reader  may  be  safely  referred  to  the  articles  relating  to 
those  diseases  for  the  principles  and  details  of  treatment  applicable  to  the 
inflammations  now  in  question. 

»  Bled.-Chir.  Trans,  vol.  li. 


16  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

In  reference  to  the  treatment  of  the  more  severe  forms  of  enteritis, 
two  main  principles  seem  now  to  be  fairly  well-established  :  they  are, 
first,  to  relieve  pain,  and  prevent,  so  far  as  may  be,  all  movements  of  the 
bowels,  by  means  of  opium  ;  secondly,  to  avoid  every  attempt  (at  least 
until  all  grave  symptoms  have  ceased)  to  force  the  bowels  by  the  admin- 
istration of  purgatives.  It  has  been  shown  quite  conclusively,  principally 
by  the  experience  derived  from  the  after-treatment  of  strangulated  hernia, 
tliat  it  is  always  dangerous  to  endeavor  to  propel  faecal  matters  through 
an  enteritic  length  of  bowel,  that  in  most  cases  the  effort  is  useless  so  far 
as  their  effectual  propulsion  is  concerned,  while,  by  the  augmented  mus- 
cular and  excretory  action  which  is  thus  produced  in  the  bowel  above,  the 
diseased  tract  below  becomes  more  and  more  distended,  almost  certainly 
more  and  more  softened,  congested,  and  inflamed,  not  infrequently  be- 
comes ruptured,  and  at  the  very  least  has  its  progress  towards  recovery 
delayed.  Besides  which,  purgatives  tend  greatly  to  increase  pain,  and 
vomiting,  and  general  distress.  And,  indeed,  when  one  considers  the 
great  length  of  time  during  which  constipation  may  continue  with  little  or 
no  influence  on  the  general  health,  how  long  patients  with  impassable 
stricture  of  the  bowel  manage  often  to  survive,  it  must  be  obvious  that 
the  constipation  of  a  disease  of  so  short  duration  as  enteritis  is  not  of  it- 
self a  grave  source  of  danger.  Clearly,  if  the  patient  is  to  get  well,  his 
recovery  must  in  the  first  instance  be  dependent  on  the  recovery  by  the 
diseased  bowel  of  its  healthy  tone,  and  capability  of  peristaltic  action  : 
and  to  this  end  our  efforts  must  be  directed.  But  experience  shows  us 
that  we  have  little  or  no  power  to  arrest  internal  inflammation,  unless  it 
be  indirectly  by  promoting  the  quiescence  of  parts,  and  by  relieving  pain 
and  irritation;  and,  for  these  purposes,  opium,  in  large  and  frequent  doses, 
is  generally  our  most  valuable  agent.  No  absolute  rule  can  be  laid  down 
with  regard  to  the  quantity  of  opium  which  should  be  given  for  a  dose, 
or  to  the  frequency  with  which  the  dose  should  be  repeated;  the  patient 
should,  however,  be  got  well  under  the  influence  of  the  drug,  and  should 
be  kept  under  its  influence.  But  the  constant  vomiting  and  the  disten- 
tion of  the  bowels  above  the  seat  of  disease,  form  a  serious,  if  not  fatal 
impediment  to  the  absorption  of  opium  received  into  the  stomach;  what 
is  swallowed  may  be  whoU}-^  vomited,  or,  if  retained,  very  partially  or  not 
at  all  received  into  the  system.  If  therefore  it  be  thought  right  to  admin- 
ister opium  by  the  mouth,  it  should  be  given  in  th«^  form  least  liable  to 
provoke,  or  to  be  rejected  by,  vomiting;  but  it  is  certainly  best  to  admin- 
ister it  in  the  form  of  suppository  or  enema,  or  to  inject  it  subcutaneously. 
But,  no  doubt,  it  is  generally  desirable,  and  even  necessary,  to  associate 
with  the  use  of  opium  other  details  of  treatment.  The  question  of  the 
abstraction  of  blood,  formerly  so  largely  employed  in  the  treatment  of 
internal  inflammations,  is  not  unlikely  to  arise;  and  it  must  be  acknowl- 
edged that  there  are  cases  in  the  early  stage  of  which  removal  of  blood 
may  be  advantageous.  When,  at  the  commencement  of  enteritis,  the 
symptoms  of  peritoneal  inflammation  are  strongly  pronounced,  there  is  no 
doubt  that  the  application  of  twenty,  thirty,  or  more  leeches  to  the  sur- 
face of  the  abdomen  is  generallv  followed  by  great  and  immediate  relief, 
if  not  by  actual  benefit.  Doubtless,  the  removal  of  blood  from  the  arm 
would  be  at  least  equally  beneficial;  and  in  cases  in  which,  at  the  same 
stage,  peritonitic  symptoms  are  less  distinct,  but  in  which  there  is  high 
fever,  I  should  not  hesitate  to  have  phlebotomy  performed.  Warm  but 
light  applications  to  the  surface  of  the  belly  generally  soothe,  even  if  they 
produce  no  further  beneficial  effect;  and  sometimes  mustard-plasters,  and 


ENTERITIS.  17 

similar  mild  counter-irritants,  give  relief.  In  the  same  way,  enemata  of 
warm  water  or  of  warm  gruel  are  at  times  useful.  There  are  few  symp- 
toms more  distressing  to  the  patient  than  the  persistent  nausea  and  vom- 
iting from  which  he  suffers,  and  few  therefore  which  we  feel  more  anxious 
to  relieve;  but  there  are  none  which,  at  all  events  at  certain  stages  of  the 
disease,  are  less  under  the  influence  of  direct  treatment.  At  any  early 
period,  when  these  symptoms  are  merely  sympathetic,  ice,  hydrocyanic 
acid,  alkalies,  lime-water,  bismuth,  carminatives,  and  other  remedial 
agents,  may  no  doubt  restrain  them  to  some  extent;  and  again,  when  the 
disease  has  begun  to  take  a  favorable  course,  they  subside  naturally,  with- 
out any  special  treatment;  but  when  the  vomiting  is  simply  the  result  of 
over-distention  of  the  stomach  and  bowels,  to  which  over-distention  there 
is  no  other  channel  of  relief,  medicine  ceases  to  have  any  power  over  it. 
The  extreme  prostration  which  so  early  manifests  itself,  is  a  strong  indi- 
cation of  the  need  of  food  and  stimulants;  but  how  can  they  be  admin- 
istered with  even  a  chance  of  benefit  ?  Their  exhibition  by  the  mouth 
tends  to  promote  sickness,  tends  also  to  add  to  the  distention  of  tlie 
already  too  much  distended  stomach  and  bowels,  while  probably,  from 
various  causes,  little  or  nothing  of  them  becomes  absorbed.  It  is  obvious, 
indeed,  as  is  insisted  on  by  Dr.  Brinton,"  that  alimentary  matters,  if  given 
by  the  mouth,  should  only  be  given  in  very  small  quantities,  and  in  a  form 
suitable  for  their  ready  appropriation  by  the  system.  They  may,  how- 
ever, be  given  in  much  larger  quantities,  and  with  none  of  the  above  ill 
effects,  and  also  with  a  much  greater  chance  of  benefit,  in  the  form  of 
enemata.  It  is  not  intended  by  the  above  remarks  to  discourage  all 
attempts  to  restrain  sickness,  or  to  supply  stimulants  or  food;  for  there 
are  cases  which  seem  hopeless,  in  which,  nevertheless,  the  bowel  is  recov- 
ering, and  in  which  the  alternative  of  life  or  death  depends  upon  the 
judicious  use  of  remedies  and  of  regimen;  but  only  to  discourage  persist- 
ence in  lines  of  treatment  when  their  effect  on  the  patient,  and  the  prog- 
ress of  the  case,  prove  their  inutility  or  harmfulness. 

^  Intestinal  Obstruction.     1867. 


OBSTRUCTION  OF  THE  BOWELS. 

By  John  Syee  Beistowk,  M.D.,  F.R.C.P. 


The  affections  which  are  here  to  be  treated  of  present  many  features  in 
common  with  enteritis,  and  their  description  is  not  infrequently  included 
in  the  description  of  that  disease.  Actual  enteritis  does  indeed  occur  at  some 
period  or  another  in  the  course  of  most  of  them;  but  their  special  claim 
to  form  a  group  by  themselves  consists  in  the  fact  of  the  existence  in  all 
of  them  of  some  mechanical  impediment  to  the  transmission  of  the  con- 
tents of  the  bowels,  in  connection  with  which  enteritis  is  apt  to,  but  does 
not  in  all  cases  necessarily,  supervene.  They  are:  1st,  constipation;  2d, 
stricture;  3d,  compression  and  traction  of  the  bowel;  4th,  internal  stran- 
gulation; 5th,  impaction  of  foreign  bodies;  and  6th,  intussusception. 

I.  Constipation". — (a)  Pathology  and  Symptoms. — Constipation  not 
only  forms  a  more  or  less  essential  element  in  the  history  of  all  the  affec- 
tions just  enumerated,  but  of  itself  induces  occasionally  insuperable  ob- 
struction; and  on  both  of  these  grounds  demands  some  brief  consideration 
here.  Prolonged  retention  of  faeces  is  within  certain  limits,  of  such  com- 
mon occurrence,  and  is  attended  with  so  little  inconvenience,  that  it 
scarcely  deserves  in  a  large  number  of  cases  to  be  regarded  as  an  abnormal 
condition.  It  may  doubtless  be  accepted  as  a  general  rule,  that  persons 
enjoying  robust  health,  and  unimpeded  in  the  regular  performance  of  their 
various  functions,  have  an  alvine  evacuation  at  least  once  daily.  Yet 
many  who  are  apparently  equally  healthy  have  their  bowels  relieved  habit- 
ually every  two  or  three  days  only,  or  even  but  once  in  a  week  or  fort- 
night. Cases  indeed  are  not  altogether  rare  in  which  some  degree  of  good 
health  has  been  maintained  for  many  years  although  faecal  evacuations 
have  during  that  time  occurred  only  at  intervals  of  six  weeks  or  two 
months.  In  the  case  of  a  lady  recorded  by  Dr.  Robert  Williams,'  in  whom 
habitual  constipation  appears  to  have  been  augmented  by  the  constant 
use  of  large  quantities  of  opium,  the  bowels  were  frequently  confined  for 
six  weeks  together,  and  during  one  year  of  her  life  there  were  only  four 
evacuations  at  intervals  of  three  months.  It  must  not  be  forgotten,  how- 
ever, that  that  degree  of  constipation  which  is  habitual  with  one  man,  and 
in  him  compatible  with  perfect  health,  may  be  and  often  is,  a  source  of 
discomfort,  if  not  of  positive  illness,  to  another  man  in  whom  its  occurrence 
is  exceptional.  Thus,  to  most  persons  whose  daily  habits  in  this  respect 
are  regular,  the  retention  of  faeces  for  two  or  three  days  is  apt  to  produce 
not  only  local  uneasiness,  such  as  fulness,  heat,  tendency  to  piles  and  flat- 
ulence, but  also  some  degree  of  general  constitutional  disturbance  indicated 

'  Dr.  Bume  on  Habitual  Constipation,  quoted  by  Mr.  Pollock  in  Hobnes'a  "  System 
of  Surgery,"  vol.  iv. 


20  DISEASES    OF   THE    INTESTINES   AND    PEEIT0NEU3I. 

by  headache,  foul  breath,  loss  of  appetite,  and  dyspeptic  symptoms,  and 
•not  unfrequently  terminates  with  more  or  less  tenesmus,  or  even  slight 
dysenteric  diarrhoea.  But  even  in  cases  in  which,  from  long  habit,  con- 
stipation has  come  to  be  regarded  as  the  normal  condition  of  things,  some 
of  the  above  specified  discomforts  do  actually  for  the  most  part  coexist  in 
some  degree  with  it,  but  having  become,  like  the  constipation,  habitual, 
cease  to  be  observed,  or  at  all  events  become  tolerable.  It  is  easy  indeed 
to  see  that  constipation  must  tend  to  produce  various  inconvenient  results: 
the  retention  of  a  mass  from  which  gaseous  matters  are  being  constantly 
evolved,  is  necessarily  productive  of  colicky  pains  and  imperative  desire 
to  discharge  flatus;  the  constant  pressure  of  a  hard  mass  immediately 
above  the  anal  outlet  causes  not  only  congestion  of  the  mucous  membrane 
of  the  part,  but  retardation  of  blood  in  the  haemorrhoidal  veins,  and  ulti- 
mately piles, — it  produces  also  not  infrequently  some  degree  of  uneasiness 
in  connection  with  the  genito-urinary  organs;  lastly,  when  defiBcation 
occurs,  the  expulsion  of  the  faeces  is  apt  in  consequence  of  their  bulk  and 
hardness  and  dryness,  not  only  to  be  attended  with  very  considerablt. 
pain,  and  perhaps  some  loss  of  blood,  but  to  be  followed  by  prolonged 
burning  or  aching,  and  (as  has  been  already  pointed  out)  by  more  or  less 
dysenteric  inflammation. 

But  much-prolonged  constipation  leads  sometimes  to  other  and  far 
more  serious  results,  namely  to  dilatation  and  hypertrophy  of  the  intestine, 
ulceration  of  its  mucous  surface,  and  perforation  of  its  walls  with  extra- 
vasation of  fsecal  matters  into  the  peritoneal  cavity.  The  dilatation  is 
sometimes  so  great,  that  the  colon  measures  from  nine  to  ten  or  even 
twelve  inches  in  circumference.  It  begins  at  a  distance  of  one  or  two 
inches  from  the  anus  (which  seems  spasmodically  contracted)  and  occu- 
pies more  or  less  of  the  remainder,  sometimes  the  whole  length  of  the 
large  intestine;  in  which  latter  case  the  chief  distention  is  observed  in 
the  rectum,  sigmoid  flexure,  and  caecum.  Hypertrophy  of  the  muscular 
coat,  which  always  accompanies  dilatation,  is  general,  but  most  marked 
in  the  sigmoid  flexure  and  upper  part  of  the  rectum,  where  the  thickness 
may  be  ^  inch  or  more.  When  ulceration  takes  place,  it  is  perhaps  partly 
due  to  yielding  of  the  mucous  membrane  from  over-distention,  partly  to 
the  constant  irritation  kept  up  by  the  faecal  mass  within.  Perforation 
may  ensue,  either  while  the  constipation  remains  unrelieved,  and  then 
either  through  the  progress  of  ulceration  or  by  laceration;  or  after  the 
bowel  has  been  emptied,  in  consequence  of  the  continuance  of  ulceration. 
Enormous  quantities  of  fascal  matter  are  sometimes  removed  from  patients 
suffering  from  aggravated  constipation;  in  Dr.  Williams'  case  above  re- 
ferred to,  numerous  round  lumps,  each  the  size  of  a  large  foetal  head,  were 
passed  at  a  time,  and  often  in  suflScient  numbers  to  fill  a  common-sized 
pail. 

I  recollect  two  fatal  cases  which  strikingly  illustrate  some  of  the  obser- 
vations which  have  just  been  made.  The  first  was  that  of  a  little  girl, 
eight  years  old,  whom  I  saw  casually  only  during  life,  and  of  whose  his- 
tory I  obtained  after  her  death  some  not  very  perfect  details.  She  had 
long  suffered  from  tendency  to  constipation;  and  it  was  stated  that  she 
had  occasionally  gone  as  long  as  three  weeks  without  passing  an  evacua- 
tion. At  the  time  of  her  admission  into  the  hospital  there  had  been  no 
relief  to  the  bowels  for  seven  weeks.  She  was  then  pale  and  thin,  had  a 
large  tense  belly,  without  pain  or  tenderness,  a  clean  tongue,  and  a  poor 
appetite.  She  had  a  "  strumous  "  look,  and  was  supposed,  I  believe,  to  be 
suffering  from  abdominal  tubercle.     She  became  gradually  more  and  more 


OBSTRUCTIOIS'    OF   THE   BOWELS.  21 

emaciated  and  anxious-looking,  while  the  belly  grew  lar<^er  and  more  tense. 
She  never  had  any  distinct  abdominal  tenderness,  but  suffered  at  times 
from  colicky  pains,  and  often  (especially  towards  the  close  of  life)  com- 
plained that  she  was  so  full  that  she  felt  as  if  she  should  burst.  During 
the  last  week  or  two  the  tongue  became  somewliat  foul,  and  she  had  fre- 
quent vomiting,  but  never  of  stercoraccous  matter.  She  passed  but  little 
urine,  and  that  was  high-colored.  She  sank  gradually  from  exhaustion, 
and  died  exactly  three  weeks  after  admission.  Amongst  other  kinds  of 
treatment  adopted  was  the  use  of  purgative  medicines  and  of  purgative 
injections  ;  and  the  medical  man  in  attendance  on  her  was  led  to  believe 
that  they  had  acted.  There  is  no  doubt,  however,  from  subsequent  inqui- 
ries, as  well  as  from  what  was  observed  after  death,  that  he  was  deceived. 
At  the  post-mortem  examination,  the  form  of  the  distended  intestines 
was  distinctly  impressed  on  the  tense  and  thin  abdominal  walls,  and  on 
opening  the  abdomen  the  enormously  enlarged  colon  was  at  first  alone 
visible.  The  distention  began  at  the  caecum  and  extended  to  within  two 
inches  of  the  anus,  where  it  ceased  abruptly.  In  the  greater  part  of  its 
extent,  the  bowel  measured  from  nine  to  ten  and  a  half  inches  in  circum- 
ference, the  greatest  amount  of  distention  being  manifested  in  the  sigmoid 
flexure.  The  muscular  walls  were  hypertrophied  from  the  ascending 
colon  to  the  lower  end  of  the  sigmoid  flexure;  and  in  the  latter  situation 
(where  the  hypertrophy  was  greatest)  they  measured  ^  inch  in  thickness. 
The  mucous  membrane  seemed  healthy  in  the  greater  part  of  its  extent, 
but  it  presented  some  congestion  here  and  there,  and  at  distant  intervals 
large  patches  in  which  there  were  groups  of  small  circular  shallow  ulcers. 
The  bowel  contained  no  flatus,  but  was  completely  full  of  thick,  semi- 
solid, olive-green-colored  fasces.  These  were  more  solid  in  the  rectum 
than  elsewhere,  and  immediately  above  the  anus  formed  an  indurated 
conical  lump.  The  small  intestines  were  also  considerably  distended, 
though  much  less  so  than  the  larger  bowel,  and  were  filled  throughout 
with  semi-fluid  olive-green-colored  contents.  The  stomach  was  small  and 
healthy  and  empty.  There  was  no  other  disease.  There  can  be  no  doubt 
that  the  death  of  the  child  was  due  to  the  neglect  of  simple  constipation, 
that  the  indurated  fiscal  lump  above  the  anal  orifice  had  formed  a  plug 
which  the  bowel  had  been  unable  to  expel,  and  which  the  accumula- 
tion of  more  and  more  fii?ces  above  and  around  it  had  served  only  to  fix 
more  securely.  That  the  bowel  had  striven  to  expel  its  contents  was 
shown  by  the  hypertrophied  condition  of  its  muscular  coat.  A  very  sim- 
ilar case  is  recorded  by  Mr.  Gay  ; '  but  there  the  nature  of  the  case  was 
recognized,  the  rectum  was  relieved  by  mechanical  means,  and  the  child 
was  saved.  The  second  case  referred  to  above  was  that  of  a  young  man, 
aged  24,  who  also  had  been\he  subject  of  habitual  constipation  ;  and  who 
on  one  occasion,  after  the  persistence  of  constipation  for  an  unusually 
long  period,  was  attacked  with  diarrhoea,  which  lasted  about  six  weeks, 
and  was  then  followed  by  sudden  peritonitis,  of  which  he  died.  There 
w^as  found  after  death  inflammation  of  the  peritoneum,  due  to  a  perfora- 
tion in  the  transverse  colon,  great  dilatation  and  thickening,  yet  almost 
complete  emptiness  of  the  whole  length  of  the  large  intestine,  and  just 
the  same  kind  of  ulceration  of  the  mucous  membrane  in  patches  as  that 
described  above.  It  was  in  one  of  these  patches  that  perforation  had 
taken  place.  Here,  as  in  the  former  case,  it  is  obvious  that  long  contin- 
ued constipation  had  caused  permanent  thickening  and  dilatation  of  the 

'  Path.  Soc.  Trans,  vol.  v. 


22  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

large  intestine,  and  ulceration  of  its  mucous  surface  ;  but  here,  addi- 
tionally, after  the  relief  of  the  constipation,  the  ulceration  had  provoked 
and  maintained  a  condition  of  diarrhoea,  and  ultimately  caused  perfora- 
tion. 

Constipation,  in  the  sense  in  which  the  word  is  here  employed,  is 
probably  always  due  to  retention  of  fjeces  in  the  lower  part  of  the  large 
intestine,  either  from  failure  to  respond  to  the  desire  for  deftBcation  when 
the  desire  presents  itself,  or  from  sluggish  action  on  the  part  of  the  lower 
bowel.  It  is  very  rare  indeed,  if  there  be  no  actual  obstruction,  that  the 
contents  of  the  alimentary  canal  do  not  pass  along  the  whole  length  of 
the  small  intestine,  and  even  along  the  colon,  at  a  tolerably  uniform  rate; 
at  all  events,  any  actual  arrest  of  their  transmission,  unless  it  be  owing 
,to  the  presence  amongst  them  of  some  massive  foreign  body,  is  proba- 
bly never  met  with  except  occasionally  in  the  cascum  and  sigmoid 
flexure. 

Constipation  is  due  to  a  variety  of  causes,  and  occurs  under  nume- 
rous different  conditions,  which  it  is  scarcely  necessary  to  enumerate  here, 
far  less  to  consider  in  detail.  It  is  frequently  caused  temporarily  by 
change  of  diet,  scene,  or  habits,  among  which  latter  may  be  included  any- 
thing which  interferes  with  the  regular  performance  of  defascation  ;  it 
happens  commonly  in  various  kinds  of  disease,  and  it  occurs  in  a  chronic 
form  in  chlorotic  or  dyspeptic  girls  and  young  women,  and  also  in  men 
and  women  (especially  the  latter)  of  sedentary  habits  or  of  sluggish  con- 
stitution. It  occurs  too,  often  perhaps  as  the  result  of  habit,  in  persons, 
young  and  old,  in  whom  no  special  cause  for  it  can  be  recognized  ;  and 
indeed,  in  many  of  the  more  remarkable  cases  that  come  under  observa- 
tion, it  is  quite  impossible  to  assign  a  definite  cause  for  it.  Among  local 
conditions  which  may  be  supposed  to  operate  in  a  greater  or  less  degree 
in  the  above  cases,  are  :  first,  modifications  in  the  character  of  the  faeces 
such  as  we  see  in  diabetes,  where,  owing  to  the  rapid  escape  of  fluid  by 
the  kidneys,  they  become  preternaturally  dry,  and  proportionately  dimin- 
ished in  bulk  ;  second,  sluggishness  on  the  part  of  the  rectum  ;  and 
third,  debility  of  the  same  part  which  may  be  primary,  and  due  in  the 
first  instance  to  simple  thinning  and  weakening  of  the  muscular  fibres, 
and  which  probably  occurs  virtually  in  all  cases  of  long-continued  consti- 
pation, when  the  bowel  has  become  dilated,  and  on  that  account  (even  if 
the  muscular  coat  be  hypertrophied)  less  competent  to  contract  eflficiently 
on  its  contents. 

(b)  The  IVeatment  of  constipation  must  be  made  to  depend  more  or 
less  upon  its  cause,  on  its  antecedents,  and  on  its  effects.  Where  it  is  a 
mere  temporary  matter,  depending  on  accidental  circumstances,  or  arising 
in  the  course  of  acute  diseases,  its  treatment  is  simple  enough,  and  needs 
no  description  here.  When  it  has  become  a  chronic  affection,  its  causes 
should  be  investigated,  and  as  far  as  possible  obviated;  and  it  may  be  ne- 
cessary to  employ  habitually  mild  aloetic  or  other  purgatives,  or  enemata. 
Sometimes  the  application  of  galvanism  to  the  surface  of  the  abdomen,  or 
to  the  abdomen  and  anus,  is  efficacious.  But  iron  and  other  tonics  also 
are  frequently  of  advantage ;  and  strychnia  is  by  many  believed  to  be  of 
great  value.  In  cases  in  which  the  rectum  becomes  filled  with  a  hard  im- 
movable mass,  and  the  bowel  above  distended  in  consequence  with  accu- 
mulated contents,  the  evacuation  of  the  rectum  by  mechanical  means  be- 
comes essential.  This  may  be  effected  sometimes  by  the  use  of  the  finger 
or  of  a  spoon,  or  some  such  instrument;  sometimes  by  the  employment 
of  copious  enemata  administered  in  the  ordinary  way;  or,  better  still  (as 


OBSTRUCTION   OF  THE   BOWELS.  23 

in  Mr.  Gay's  case),  by  directing  a  forcible  stream  of  warm  water,  con- 
ducted from  a  height  by  means  of  a  tube,  into  the  rectum,  allowing  it  to 
play  upon  the  faecal  mass  for  half  an  hour  or  so  at  a  time,  and  thus  to 
cause  its  disintegration,  and  either  effect  or  facilitate  its  removal. 

II.  Stricture. — By  this  term  is  meant  a  circumscribed  diminution  in 
the  calibre  of  the  bowel,  due  either  to  contraction  of  the  mucous  and  sub- 
mucous tissues  (the  consequence  usually  of  ulceration),  or  to  some  deposit 
or  growth  involving  the  general  thickness  of  the  walls  and  encroaching 
on  the  canal,  or  to  some  spasmodic  action  of  the  circular  muscular  fibres. 
It  is  occasionally  the  result  of  malformation. 

(a)  Pathology. — Congenital  stricture,  though  in  some  of  its  forms  by 
no  means  rare,  is  an  affection  the  treatment  of  which  belongs  almost  ex- 
clusively to  the  surgeon,  and  one,  therefore,  that  needs  little  more  than 
incidental  mention  here.  It  is  limited,  indeed,  with  few  exceptions,  to 
the  lower  extremity  of  the  bowel — the  rectum  and  the  anus — one  or  both 
of  which  parts  may  be  found  at  birth  to  be  impervious  or  absent,  or  re- 
duced to  a  mere  fistulous  canal  or  orifice,  while,  in  addition,  the  lower 
end  of  the  fully-dilated  bowel  above  occasionally  communicates  with  the 
vagina  in  the  female,  or  with  the  bladder  or  urethra  in  the  male.  Very 
much  more  rarely,  congenital  stricture  is  met  with  in  the  duodenum,  at  or 
above  the  point  at  which  the  common  bile  duct  discharges  itself.  Two 
cases  of  this  kind  are  recorded  in  the  twelfth  volume  of  the  "  Pathologi- 
cal Society's  Transactions,"  one  by  Dr.  Wilks,  the  other  by  Dr.  G.  Bu- 
chanan. In  both,  a  kind  of  membranous  septum  existed  at  the  point  re- 
ferred to,  and  the  portion  of  the  duodenum  above  was  thickened  and 
dilated,  forming  a  mere  prolongation  of  the  pyloric  end  of  the  stomach. 
In  Dr.  "VVilks's  case  the  bile  duct  opened  immediately  below  thfe  septum, 
which  was  impervious;  and  the  child  died  at  the  end  of  thirty-eight  hours, 
its  death  being  preceded  by  vomiting  and  convulsions.  In  Dr.  Buchanan's 
case,  the  duct  opened  on  the  under-surface  of  the  septum,  the  septum 
presented  a  minute  central  orifice,  and  the  child,  a  girl,  lived  eighteen 
months.  According  to  the  history,  she  was  apparently  quite  well  up  to 
within  a  month  of  her  death,  probably  because  (as  is  supposed)  she  had 
hitherto  been  fed  only  from  the  breast  and  with  milk.  She  appears  dur- 
ing the  last  month  of  life  to  have  suffered  from  constant  vomiting,  great 
restlessness  and  uneasiness  or  pain,  together  with  (during  the  earlier  part 
of  that  time)  frequent  convulsions.  It  may  be  added,  that  in  this  case, 
where  the  parts  were  examined  with  much  minuteness,  the  septum  was 
ascertained  to  consist  of  a  duplicature  of  mucous  membrane,  not  unlike  an 
enlarged  valvula  connivens,  inclosing  a  few  scattered  muscular  fibres  pro- 
longed from  a  stout  circular  band  which  surrounded  its  base. 

Although  spasm  of  the  circular  muscular  fibres  has  been  given  above 
as  one  of  the  causes  of  intestinal  stricture,  and  although  it  doubtless  does 
form  a  very  important  element  in  many  cases  of  fatal  obstruction  of  the 
bowels,  it  is  certainly  of  very  rare  occurrence,  as  an  independent  affection, 
and  may  be  considered  practically  as  limited  to  the  rectum  and  anus. 
And  indeed,  even  in  these  parts,  spasmodic  obstruction  is  probably  always 
attended  with  some  ulceration  of  the  adjacent  mucous  membrane,  to 
which  there  is  reason  to  believe  it  secondary.  Thus  spasmodic  contraction 
of  the  sphincter  ani,  an  affection  which  may  be  regarded  as  exclusively 
surgical,  seems  to  be  dependent  on  the  formation  of  an  ulcer,  at  or  within 
the  verge  of  the  anus;  and  not  very  infrequently  spasmodic  contraction, 
with  great  hypertrophy  of  the  muscular  tissue,  is  met  with  as  one  of  tho 
troublesome  sequelae  of  dysenteric  ulceration  of  the  rectum. 


24  DISEASES    OF   THE    IISTTESTINES    AND    PERITONEUM. 

But  the  varieties  of  stricture  with  which  we  have  here  to  deal  particu- 
larly, are  those  in  wliich,  according'  to  the  definition  with  which  we  started, 
the  stricture  is  due  either  to  the  contraction  of  the  mucous  and  submucous 
tissues,  or  to  some  deposit  or  g'rowth  involving  the  general  thickness  of 
the  walls.  The  cicatrization  which  follows  ulcerative  destruction  of  the 
mucous  membrane  is  a  common  cause  of  diminution  of  the  calibre  of  the 
bowel.  But  what  particular  kinds  of  ulceration  are  most  apt  to  be  fol- 
lowed by  this  condition  is  not  very  clear.  Indeed,  in  most  cases  where 
stricture  from  ulceration  is  found  after  death,  there  is  nothing  in  the  his- 
tory to  guide  our  judgment  in  this  respect.  It  is  certain,  however,  that 
in  order  to  produce  any  marked  constriction,  the  area  of  ulceration  must 
either  have  been  considerable,  or  must  have  extended  round  the  bowel. 
There  is  reason  to  believe  that  irritant  poisons,  in  consequence  of  their 
corrosive  effects  on  the  mucous  membrane,  lead  occasionally  to  the  pro- 
duction of  stricture  of  the  intestine,  especially  in  its  upper  part,  just  as 
they  occasionally  cause  oesophageal  stricture.  There  is  no  doubt  that 
tubercular  ulceration  of  the  bowels,  which  very  commonly  forms  annular 
patches  or  occupies  extensive  tracts,  and  which  not  at  all  infrequently 
undergoes  more  or  less  perfect  cicatrization,  is  a  yet  more  frequent  cause 
of  stricture,  either  in  the  lower  part  of  the  ileum,  or  in  the  caecum,  or  in 
some  part  of  the  colon.  Dysenteric  ulceration  of  the  large  intestine  is 
also  a  distinct  cause  of  stricture;  as  again  is  the  separation  by  sloughing 
of  an  invaginated  portion  of  bowel.  The  ulcers  of  typhoid  fever,  on  the 
other  hand,  are  known  to  result  very  rarely,  if  ever,  in  obvious  contraction 
of  the  calibre  of  the  bowel:  although  it  is  pretty  certain  that  even  in  this 
case,  when  the  ulceration  has  spread  and  become  extensive,  marked  con- 
striction may  attend  its  cicatrization.  When  stricture  is  due  to  ulceration, 
we  find  the  mucous  surface  contracted,  sometimes  completely  cicatrized, 
sometimes  presenting  unhealed  spots  of  ulceration,  with  fungous  excres- 
cence or  granulations,  and  separated  from  the  subjacent  muscular  coat  by 
a  more  or  less  abundant  deposit  of  dense  fibroid  tissue.  The  stricture 
itself  may  be  a  mere  ring,  or  it  may  occupy  several  inches  of  the  lengtli 
of  the  bowel;  I  have  seen  the  whole  ca?cum  thus  reduced  into  a  channel 
barely  capable  of  admitting  a  goose's  quill.  Another  cause  of  stricture, 
limited  probably  to  the  large  intestine,  is  the  growth  of  that  fibroid  mate- 
rial which  resembles,  but  has  of  late  been  distinguished  from,  true  scirrhus. 
This  generally  involves  all  the  coats  to  a  greater  or  less  extent,  encroach- 
ing, as  it  grows,  upon  the  intestinal  tube.  Sometimes,  but  not  necessa- 
rily, its  surface  ulcerates.  A  growth  probably  identical  with  this,  occur- 
ring in  so-called  "  pelvic  cellulitis,"  sometimes  involves  the  walls  of  the 
rectum  and  causes  stricture  there.  But  by  far  the  most  frequent  cause 
of  stricture  is  the  development  of  cancerous  disease  in  the  coats  of  the  in- 
testine. This  is  sometimes  local,  or  at  all  events  of  primary  origin  in  the 
bowel,  being  then,  perhaps  without  exception,  a  disease  of  the  large  intes- 
tine; but  more  frequently  it  involves  the  gut  by  spreading  to  it  from  some 
neighboring  part,  as  from  the  peritoneum,  the  mesenteric  or  other  abdom- 
inal lymphatic  glands,  from  the  substance  of  the  gastro-hepatic  omentum, 
from  the  cellular  tissue  of  the  venter  ilei  or  pelvis,  or  from  the  genito- 
urinary organs. 

The  presence  of  a  stricture  is  always  a  more  or  less  serious  impediment 
to  the  progress  of  fascal  matters  along  the  bowel;  and  in  all  cases  then'- 
fore  leads  in  a  greater  or  less  degree  to  certain  results.  These  arc  :  first, 
undue  accumulation  of  fiscal  matter  above  the  stricture,  with  proportion- 
ate dilatation  of  the  bowel  there;  second,  hypertrophy  of  the  muscular 


OBSTRUCTION   OF   THE   BOWELS.  25 

parietes  of  the  dilated  bowel;  and  third,  diminution  in  calibre  and  even 
atrophy  of  the  bowel  below.  It  is  an  interesting^  fact  that,  in  cases  of 
stricture  of  the  colon,  the  greatest  degree  of  dilatation  is  often  found,  not 
in  the  portion  of  intestine  immediately  above  the  stricture,  but  in  the 
cajcum.  The  tighter  and  the  longer  a  stricture,  the  more  exaggerated, 
other  things  being  equal,  will  be  the  several  consequences  just  described; 
and  the  more  danger  will  there  be  of  the  supervention  of  permanent  ob- 
struction. Yet  it  is  a  very  remarkable  fact,  that  very  tight  strictures  are 
not  infrequently  found  after  death  in  cases  in  which  during  life  there  has 
been  no  suspicion  of  their  presence.  Allusion  has  been  already  made  to  a 
case  which  was  under  my  own  care,  wherein  the  caicum  was  contracted 
into  a  channel  two  inches  long,  and  about  the  size  of  a  goose's  quill;  yet 
the  patient  had  no  symptoms  of  stricture,  and  died  of  acute  pneumonia. 
But  it  is  in  the  small  intestine  especially  that  stricture  is  apt  to  be  pres' 
ent  without  producing  any  of  its  characteristic  symptoms — a  phenomenon 
which  is  probably  due,  in  part,  at  least,  to  the  fact  that  the  contents  of 
the  small  intestine  are  usually  much  more  fluid  than  those  of  the  large, 
and  are  consequently  much  more  readily  propelled  through  a  very  narrow 
orifice.  Indeed,  Dr.  Buchanan's  case  already  cited,  and  many  others 
that  might  be  quoted,  show  clearly,  what  also  common  sense  would  lead 
us  to  surmise,  that  the  more  solid  the  matters  are  which  ought  to  be  forced 
through  a  stricture,  the  more  likely  are  they  to  be  arrested  there,  and  thus 
to  reader  the  obstruction  complete.  It  may  be  added,  that  the  lodgment 
of  ftBces  above  a  stricture  is  very  apt,  not  only  to  prevent  the  complete 
cicatrization  of  the  ulcer  by  which  the  stricture  itself  may  have  been  origi- 
nally produced,  but  to  cause  erosion  and  ulceration  in  the  dilated  bowel 
above,  a  contingency  which  is  still  more  likely  to  arise  when  cherry-stones 
or  plum-stones  or  other  hard  bodies  form  a  part  of  the  accumulation. 
And,  further,  it  may  be  added,  that  perforation  of  the  bowel  at  or  above 
the  seat  of  stricture  is  not  of  very  infrequent  occurrence,  generally  as  the 
result  of  perforating  ulcer,  occasionally  as  the  result  of  laceration  from 
associated  softening  and  over-distention. 

Stricture  may  be  met  with  in  any  part  of  the  intestine,  yet  it  occurs 
in  different  parts  with  very  different  degrees  of  frequency.  The  published 
statistics  of  fatal  cases  show  that  its  occurrence  as  a  fatal  disease  in  the 
small  intestine  is  comparatively  rare  (according  to  Dr.  Brinton,'  in  8  out 
of  every  100  cases)  and  that  as  regards  the  large  intestine  (to  quote  again 
Dr.  Brinton's  figures,  with  which  those  of  other  writers  agree  pretty 
closely),  out  of  100  fatal  cases,  4  are  in  the  ca3cum,  10  in  the  ascending 
colon,  11  in  the  transverse  colon,  14  in  the  descending  colon,  30  in  the 
sigmoid  flexure,  and  30  in  the  rectum.  Dr.  Brinton  calculates  that  stric- 
ture occurs  three  times  in  men  to  twice  in  women;  and  that  the  average 
age  of  death  is  44f  years. 

(b)  The  Symptoms  to  which  stricture  gives  rise  vary  greatly  accord- 
ing to  circumstances,  especially  according  to  its  position,  its  degree,  its 
cause,  and  its  complications.  As  has  been  already  pointed  out,  stricture 
of  the  small  intestine  very  rarely  causes  symptoms  sufficiently  character- 
istic to  enable  us  to  diagnose  its  presence,  and  rarely  causes  death  except 
by  the  accession  of  complications  which  themselves  are  not  distinctive. 
It  probably  gives  a  liability  to  colicky  pains,  and  to  some  degree  of  nausea 
and  sickness.     Indeed,  in  the  case  of  the  large  intestine  the  symptoms 

'  "Intestinal  Obstruction,"  by  William  Brinton,  M.D.,  F.R.S.     1867.     Frequent"^ 
reference  is  made  to  tliis  work  throughout  the  present  article. 


26  DISEASES   OF  THE   INTESTINES   AND   PERITONECM. 

produced  by  stricture  may  be  for  a  long  time  vagxie  and  inconclusive,  and 
even  misleading.  The  patient  suffers  perhaps  for  weeks,  or  months,  or 
years,  with  occasional  attacks  of  colicky  pain,  associated,  it  may  be,  with 
more  or  less  constipation;  but  not  infrequently  during  the  earlier  period 
of  his  malady  diarrhoea  may  be  a  yet  more  prominent  symptom.  If,  how- 
ever, the  obstruction  be  in  the  vicinity  of  the  rectum,  solid  motions  gen- 
erally soon  assume  a  narrow  tape-like  or  pipe-like  form.  Occasionally  the 
symptoms  of  obstruction  come  on  quite  suddenly;  but  most  frequently 
some  degree  of  constipation  long  precedes  the  occurrence  of  complete  ob- 
struction; and  sometimes,  too,  it  happens  that  the  patient,  previous  to 
his  final  attack,  may  have  experienced  one  or  two  or  more  similar  atttacks, 
which  have,  however,  yielded  to  treatment.  The  symptoms  which  attend 
and  indicate  impassable  stricture  are  insuperable  constipation,  painful  peris  • 
talsis  coming  on  periodically,  and  often  rendering  itself  audible  by  borbo* 
rygmi,  and  visible  through  the  abdominal  walls,  abdominal  fulness  and  un- 
easiness, followed  after  a  time  by  nausea  and  vomiting — the  vomited  mat- 
ters becoming  finally  stercoraceous — and  death  at  last  from  simple  asthenia. 
Febrile  symptoms  and  abdominal  tenderness  are  often  absent  from  first  to 
last:  but  sometimes  inflammation  supervenes,  or  perforation  takes  place, 
and  then  enteritic  or  peritonitic  symptoms  become  superadded.  When 
the  case  is  free  from  these  or  other  complications,  its  progress  is  essen- 
tially chronic,  and  the  patient,  if  not  improperly  treated,  lives  for  a  consider- 
able time,  often  for  many  weeks.  The  duration  of  life  in  these  cases  may 
be  said  somewhat  roughly  to  vary  between  two  weeks  and  three  months. 
Indeed,  when  we  consider  that  constipation  may  continue  for  three 
months  or  more  with  comparatively  little  injury  to  the  system,  it  is  im- 
possible not  to  believe  that  persons  with  simple  impassable  stricture  of  the 
rectum  may,  under  favorable  circumstances,  survive  for  even  a  longer 
period  than  that. 

It  is  always  satisfactory,  and  sometimes  highly  important,  to  ascertain 
the  exact  site  of  stricture ;  and  in  coming  to  a  conclusion  on  this  point,  it 
is  well  to  bear  in  mind  that  at  least  three-fourths  of  the  strictures  of  the 
large  intestine  are  situated  to  the  left  of  the  mesial  line  of  the  abdomen. 
We  need  not,  however,  in  all  cases  limit  ourselves  to  a  simple  calculation 
of  chances.  It  is  natural  to  believe  that  the  distention  of  the  bowel 
above  the  stricture,  and  its  collapse  below,  should  reveal  themselves  to 
manual  if  not  to  ocular  examination  of  the  abdomen,  and  sometimes,  no 
doubt,  the  form  and  position  of  a  struggling,  or  even  of  a  quiescent, 
length  of  distended  bowel,  may  by  such  means  be  clearly  identified. 
Fulness  and  dulness  and  weight  in  the  course  of  the  cjecum  and  ascend- 
ing colon,  or  on  the  right  side  of  the  belly,  might  thus  indicate  a  stricture 
at  or  about  the  hepatic  flexure,  and,  associated  with  the  same  conditions 
extending  across  the  epigastrium,  might  indicate  stricture  at  the  splenic 
flexure  or  in  the  descending  colon;  whereas  fulness,  and  the  like,  limited 
to  the  left  side  of  the  belly,  or  most  pronounced  in  that  region,  might 
equally  be  indicative  of  stricture  in  the  sigmoid  flexTire  or  rectum.  But 
thickness  or  rigidity  of  the  abdominal  walls,  or  tenderness,  or  the  pres- 
ence of  tumors,  or  the  altered  positions  which  greatly  distended  tracts  of 
bowel  are  apt  to  assume,  often  interfere  to  prevent  the  easy  recognition 
of  even  extreme  differences  of  intestinal  dilatation  and  fulness.  Dr. 
Brinton  maintains  that  the  amount  of  fluid  which  may  with  care  be  in- 
jected per  anvm,  is  a  very  valuable  guide  in  estimating  the  point  of 
stricture.  He  says:  "  With  a  maximum  injection  of  a  pint  of  wann  bland 
liquid,  the  obstructioi  of  an  ordinary  male  adult  may  be  referred  to  a 


OBSTBUCTION   OF  THE   BOWELS.  27 

point  not  lower  than  the  upper  end  of  the  rectum.  A  pint  and  a  half, 
two  pints,  three  pints,  belong  to  corresponding  segments  of  the  sigmoid 
flexure.  The  descending  and  transverse  colon  accept  a  larger  but  more 
irregular  quantity."  But  here  again  there  is  evidently  very  abundant 
room  for  error;  for  it  is  certain  that  not  all  contracted  bowels  are  tolerant 
in  an  equal  degree  of  mechanical  distention,  and  there  can  be  no  doubt  I 
that  a  stricture,  which  may  prevent  the  passage  of  hard  faecal  matter  in 
one  direction,  may  yet  allow  of  the  transmission  of  thin  fluids  in  the  oppo- 
site direction.  Lastly,  when  the  stricture  is  a  short  distance  only  from 
the  anus,  its  presence  may  often  be  ascertained  by  the  introduction  of 
the  finger,  or,  as  has  been  suggested,  of  the  entire  hand;  and  if  it  bo 
beyond  the  reach  of  actual  touch,  yet  in  the  rectum,  the  careful  introduc- 
tion of  a  bougie  may  perhaps  reveal  its  position.  But  it  must  not  be  for- 
gotten that  the  curvatures  of  the  rectum,  and  the  prominent  folds  of  its 
mucous  membrane,  are  such  impediments  to  this  latter  mode  of  examina- 
tion as  to  rob  it  of  very  much  of  its  value;  in  addition  to  which,  it  is  at- 
tended with,  at  all  events  in  many  cases,  considerable  risk  of  damage. 

(c)  Treatment. — Whenever  we  have  reason  to  believe  in  the  presence 
of  a  stricture,  it  is  obviously  desirable  that  nothing  which  is  not  in  a  per- 
fectly fluid  or  pultaceous  condition  should  be  allowed  to  enter  the  bowel, 
— therefore,  that  the  food  taken  habitually  should  be  easy  of  digestion, 
thoroughly  well  masticated,  and  not  more  abundant  than  is  absolutely 
necessary  for  the  preservation  of  health,  and  especially  that  neither  plum 
nor  cherry  stones,  nor  even  pips,  should  be  swallowed :  secondly,  that  the 
bowels  should  themselves  be  kept  as  far  as  possible  in  a  quiet  condi» 
tion — in  other  words,  whilst  constipation  should  as  far  as  possible  be  pre- 
vented, diarrhoea  and  painful  gripings  should  equally  be  guarded  against. 
If  there  be  constipation,  it  may  be  directly  relieved,  or  the  bowel  above 
the  seat  of  stricture  may  be  encouraged,  as  it  were,  to  propel  its  contents 
by  the  use  of  simple  non-purgative  enemata;  but  purgatives  of  all  kinds, 
certainly  anything  like  active  purgation,  should  be  religiously  eschewed. 
Should  the  stricture  be  in  the  rectum,  and  within  reach,  it  may  of  course 
admit  of  dilatation  and  relief  by  the  use  of  a  bougie.  When  symptoms 
indicative  of  complete  stoppage  manifest  themselves,  the  wish  to  employ 
active  measures  to  relieve  the  patient's  distress  naturally  obtrudes  itself; 
but  such  measures  are  for  the  most  part  even  less  admissible  now  than 
formerly.  Enemata  may  be  of  advantage,  partly,  as  before  pointed  out, 
to  guide  our  judgment  as  to  the  seat  of  the  stricture,  partly  (if  the  stric- 
ture be  in  the  large  intestine)  for  the  purpose  of  promoting  the  relief  of 
the  bowel  above  the  impediment;  but  purgatives  are  not  only  useless,  but 
almost  certain  to  do  serious  mischief,  if  not  to  cause  actual  perforation. 
On  opium  and  other  sedatives,  and  soothing  applications  locally  applied, 
utterly  inadequate  though  they  generally  are,  must  yet  be  our  chief  reli- 
ance, so  far  as  ordinary  medical  treatment  is  concerned.  But  in  all  such 
cases  a  time  comes  when  the  advisability  of  forming  a  communication  from 
without  with  the  portion  of  bowel  above  the  stricture — in  other  words, 
the  attempt  to  establish  an  artificial  anus — becomes  a  serious  question. 
When  the  stricture  is  in  the  large  intestine,  as  it  generally  is,  Amussat's 
operation,  in  one  or  other  loin,  is  that  which  would  of  course  be  chosen 
for  performance;  and  although  it  is  obviously  incompetent  to  cure  the 
stricture,  it  avails  very  often  to  prolong  life,  and  sometimes  to  prolong  it 
for  a  considerable  period.  If  the  stricture  happens  to  be  in  the  small  in- 
testine, Litre's  operation  is  alone  available. 


28  DISEASES    OF   THE   IT^TESTINES    AND    PERITONEUM. 

III.  Compression  ajtd  Traction. — Dr.  Hilton  Fagge '  has  with  great 
reason  distinguished  on  the  one  hand  from  stricture,  on  the  other  from 
internal  strangulation,  a  class  of  cases  related  to  both,  which  is  yet  clearly 
distinguishable  from  them,  and  which  he  designates  "  Contractions." 
They  arc  cases  in  which  the  bowel  becomes  obstructed  by  the  compres- 
sion, or  the  pressure,  or  the  traction  exerted  upon  it  by  adhesions,  or 
growths,  or  deposits  situated  externally  to  it,  and  in  which  there  is  no 
contraction  inherent  in  the  walls  themselves,  and  not  necessarily  or  gener- 
ally any  strangulation. 

(a)  Pathology. — Under  the  above  heading  may  be  included  those  cases 
in  which  the  return  becomes  obstructed,  and  defsecation  rendered  painful 
or  difficult,  in  consequence  of  the  pressure  exerted  on  that  part  of  the 
bowel,  either  by  an  enlarged  or  displaced  uterus,  or  by  a  uterine  or  ovarian 
tumor.  It  is  conceivable,  of  course,  that  any  form  of  abdominal  tumor 
may  by  pressure  obstruct  the  alimentary  canal  in  some  part  of  its  course. 
I  recollect  one  case  of  death  by  rupture  of  the  abdominal  aorta,  in  which 
the  blood,  effused  and  coagulated  in  the  sub-peritoneal  tissue,  had  so  sur- 
rounded and  compressed  the  third  part  of  the  duodenum  that  the  finger 
passed  along  it  with  difficulty;  and  while  the  stomach  and  duodenum 
above  contained  a  considerable  quantity  of  contents,  the  intestine  below 
was  perfectly  empty. 

But  the  cases  which  are  now  more  particularly  referred  to  are  those 
in  which  obstruction  is  due  to  the  embarrassment  of  a  greater  or  less 
length  of  bowel,  caused  by  the  presence  on  its  outer  surface  of  lymph  or 
false  membrane,  which  binds  it  more  or  less  firmly  to  the  surrounding 
parts,  and  sometimes  constricts,  sometimes  leads  to  the  formation  of  sharp 
angular  bends.  The  adhesions  are  often  produced  by  circumscribed  peri- 
tonitis, but  more  frequently,  perhaps,  are  developed  in  the  course  of  peri- 
toneal tubercle  or  cancer.  In  some  cases  the  intestine  has  been  incarcer- 
ated in  a  hernia,  and  portions  of  it  have  become  invested  in  adhesions, 
which  attach  it,  perhaps,  to  the  neck  or  some  other  part  of  the  sac,  or  to 
the  omentum;  in  others,  the  transverse  colon  or  sigmoid  flexure,  or  some 
other  tract  of  bowel,  is  hooked  down,  as  it  were,  by  bands  of  lymph  to  the 
uterus,  or  ovary,  or  some  other  structure  within  the  pelvis;  in  others, 
again,  several  contiguous  coils  of  small  intestine  are  tightly  bound  to- 
gether, forming  a  kind  of  tangled  mass.  Fatal  cases  of  compression  or 
.raction  always  furnish  distinct  evidence  of  more  or  less  complete  obstruc- 
tion, in  the  contraction  and  emptiness  of  the  bowel  below,  and  in  the  dila- 
tation, hypertrophy,  and  fulness  of  the  bowel  above;  but  the  part  in  which 
the  actual  obstruction  has  taken  place,  though  contracted  and  more  or 
less  empty,  is  frequently  found  to  admit  with  ease  of  the  passage  of  the 
finger,  or  even  of  some  larger  body.  The  immediate  cause  of  obstruction 
indeed  is  not  generally  a  simple  tight  constriction,  but  consists  sometimes 
in  a  comparatively  slight  compression  of  a  considerable  length  of  bowel, 
which  thus  becomes  embarrassed  in  its  action,  and  sometimes  in  the  pres- 
ence of  a  sudden  bend  or  twist,  the  upper  portion  of  which  becoming  dis- 
tended presses  upon  and  flattens  the  portion  beyond,  and  so  renders  it 
impervious,  and  in  association  with  tliese  doubtless  a  greater  or  less  de- 
gree of  spasmodic  contraction.  Sometimes,  however,  the  obstruction  is  as 
sharp  and  definite  as  any  stricture. 

Dr.  Fagge  points  out  (and  in  the  opinion  which  he  expresses  I  entirely 

'  In  an  excellent  paper  in  the  Guy's  Hospital  Reports  for  1869,  to  which  frequent 
reference  is  made  in  the  course  of  this  article. 


OBSTRUCTION    OF   THE    BOWELS.  29 

agree  with  him)  that  these  cases  are  of  far  more  frequent  occurrence  in 
the  small  intestine  than  in  the  large,  and  that  in  a  clinical  point  of  view 
they  may  be  regarded  as  the  strictures  of  the  smaller  bowel. 

(b)  /Sf/mptoms  and  IVeatment. — The  symptoms  of  the  affection  now 
under  consideration  are  almost,  if  not  quite,  identical  with  those  of  stric- 
ture. In  both  cases,  when  the  impediment  to  the  due  action  of  the  bowel 
is  associated  with  abdominal  cancer  or  tubercle,  or  any  other  form  of 
adventitious  growth,  the  symptoms  connected  with  these  complications 
mask,  if  they  do  not  conceal,  the  symptoms  due  to  obstruction.  In  both 
cases,  when  no  such  complications  are  present,  the  symptoms  sometimes 
come  on  quite  suddenly,  sometimes  creep  on  insidiously  with  occasional 
colicky  pains,  limited  but  powerful  peristaltic  movements,  and  gradually 
increasing  obstinacy  of  the  bowels;  and  sometimes  the  patient  suffers 
from  one  or  more  severe  attacks  of  total  constipation,  which  yield  after 
a  time  to  nature  or  to  treatment,  and  in  this  respect  only  differ  from  the 
final  and  fatal  attack.  In  both  cases,  again,  the  disease,  though  not  en- 
tirely free  from  the  danger  of  the  supervention  of  peritonitis  or  enteritis, 
is  still  not  necessarily  complicated  with  symptoms  of  inflammation,  and  its 
course,  therefore,  tends  to  be  peculiarly  chronic,  lasting  sometimes  for 
weeks,  and  its  close  is  usually  determined  by  gradual  exhaustion  only. 
Dr.  Fagge  thinks  that  cases  of  this  kind  are  to  be  distinguished  by  their 
chronicity,  by  the  occurrence  of  obstruction  rather  in  the  small  intestine 
than  in  the  large,  and  by  the  powerful  and  well-marked  vermicular  move- 
ments which  occur,  often  nearly  to  the  last,  in  the  length  of  bowel  above 
the  impediment.  He  points  out  that  it  is  in  cases  of  chronic  impediment 
especially  that  the  bowel  above  becomes  hypertrophied  as  well  as  dilated, 
and  he  argues  that  it  is  therefore  probably  in  these  same  cases  (stricture 
and  compression)  that  the  movements  of  the  bowel,  in  their  endeavors  to 
overcome  the  impediment,  are  most  powerful  and  most  obvious.  In  con- 
firmation of  this  view,  I  may  state  that  the  cases  in  which  I  have  myself 
most  distinctly  traced  the  peristaltic  movement  of  the  bowel  have  been 
cases  of  the  kind  in  question. 

It  is  needless  to  draw  any  distinction  here  as  regards  treatment  be- 
tween stricture  and  compression  of  the  bowel. 

The  following  case  may  be  quoted  as  a  typical  example  of  the  affection 
which  has  just  been  described.  A  man,  forty  years  of  age,  was  attacked 
suddenly,  seven  weeks  before  his  admission  into  St.  Thomas's,  with  severe 
colicky  pains,  which  confined  him  to  his  bed  for  two  or  three  days.  He 
improved,  but  at  the  end  of  a  few  days  had  a  recurrence  of  the  same 
symptoms,  lasting  for  about  three  weeks,  and  attended  with  nausea,  vom- 
iting, and  constipation.  Then  for  ten  days  he  became  free  from  pain  and 
apparently  convalescent.  But  ten  days  before  his  admission  all  his  symp- 
toms returned  with  increased  severity;  and  during  this  time  vomiting  was 
pretty  constant  and  his  bowels  remained  unopened,  although  strong  pur- 
gatives were  several  times  administered.  On  admission  his  face  was 
anxious,  but  his  tongue  was  clean  and  his  pulse  quiet.  He  vomited  regu- 
larly two  hours  after  taking  food.  The  belly  was  distended  and  tympa- 
nitic, and  somewhat  tender;  he  complained  of  constant  pain  in  it;  and 
severe  exacerbations  of  pain,  lasting  two  or  three  minutes,  and  attended 
with  a  gurgling  sound,  came  on  about  every  five  minutes.  The  vomiting 
became  stercoraceous  four  days  after  admission,  and  continued  so  thence- 
forth. The  bowels  were  never  acted  on  except  by  enemata,  which  brought 
away  fa?cal  matters  in  gradually  decreasing  quantities.  The  distention 
and  tenderness  of  the  belly  continued,  if  they  did  not  increase;  and  the 


30  DISEASES   OF   THE  INTESTINES   AND   PERITONEUM. 

paroxysms  of  more  intense  pain  coming  on  every  few  minutes  troubled 
nim  almost  to  the  last.  During'  these  paroxysms,  the  violent  peristaltic 
movements  of  the  bowels  could  be  followed  through  the  abdominal  pari- 
etes  with  the  greatest  facility.  He  had  no  distinct  febrile  symptoms,  and 
no  hiccough;  he  continued  perfectly  sensible,  and  died  of  simple  exhaus- 
tion just  three  weeks  after  admission.  At  the  post-mortem  examination, 
the  small  intestines  generally  were  found  to  be  enormously  distended,  and 
their  surface  a  little  heightened  in  color,  and  marked  with  longitudinal 
bands  of  rather  intense  capillary  congestion.  From  the  middle  of  the 
ileum  to  within  a  foot  of  the  caecum  the  coils  were  adherent  to  one  another 
and  to  the  brim  of  the  pelvis  by  bands  and  filaments  of  false  membrane, 
and  were  so  entangled  that  their  direction  was  traceable  with  difficulty. 
The  portion  of  bowel  involved  was  for  the  most  part  somewhat  dilated; 
its  lowest  third,  however,  was  contracted  and  empty,  as  also  was  the  por- 
tion between  this  and  the  caecum.  The  stomach  and  small  intestines  down 
to  the  seat  of  contraction  were  dilated,  and  full  of  thin  pea  soup-like  fluid; 
the  caecum  and  large  intestines  were  contracted  throughout,  but  here  and 
there  in  the  ascending  colon  were  small  lumps  of  hardened  faeces.  The 
mucous  membrane  of  the  alimentary  canal  was  healthy  everywhere. 
There  was  no  hernia,  no  intussusception,  and  no  part  of  the  bowel  along 
which  the  finger  could  not  readily  be  passed. 

IV.  Internal  Steangulation. — Internal  Strangulation  arises  from 
similar  causes  to  those  which  produce  ordinary  strangulated  hernia, 
namely,  constriction  or  nipping  of  a  portion  of  bowel  by  the  edges  of 
some  natural  or  artificial  orifice  through  which  it  protrudes,  with  conse- 
quent arrest  of  the  circulation  of  blood  in  it,  and  impediment  to  the  pas- 
sage of  faecal  matters  along  it.  Such  orifices  are  the  foramen  of  Winslow, 
congenital  or  acquired  perforations  in  the  mesentery,  meso-colon,  great 
omentum,  or  other  peritoneal  duplicatures,  or  apertures  formed,  with  the 
aid  of  neighboring  parts,  by  bands  of  fibroid  tissue  (the  result  generally 
of  some  inflammatory  process)  extending  from  one  point  of  the  peritoneal 
surface  to  another.  And  it  is  obvious  that  the  same  accidental  conditions 
which  lead  to  the  protrusion  of  intestine  into  an  ordinary  hernial  sac,  may 
equally  lead  to  the  protrusion  of  a  knuckle  or  loop  or  still  larger  mass  of 
bowels  into  one  of  these.  But,  of  course,  it  no  more  follows  in  the  one 
case  than  in  the  other  that  strangulation  should  either  immediately,  or  at 
any  subsequent  period,  follow  upon  this  displacement;  although  in  both 
cases  there  is  always  imminent  danger  of  its  occurrence. 

(a)  Pathology. — Protrusion  of  bowels  through  the  foramen  of  Winslow 
must  be  an  exceedingly  rare  event.  Rokitansky,'  however,  alludes  to  a 
case  in  which  he  found  this  the  cause  of  strangulation  of  a  large  portion 
of  small  intestine.  Perforation  of  the  various  duplicatures  of  peritoneum, 
with  the  passage  of  intestine  through  the  perforation,  and  consequent 
strangulation,  is  a  much  more  frequent  occurrence.  This  accident  appears 
to  be  most  common  in  connection  with  the  mesentery,  and  then  generally 
to  follow  upon  laceration  from  violence.  Next  probably  in  order  of 
frequency  it  is  met  with  in  connection  with  the  great  omentum.  And 
cases  are  recorded  in  which  death  has  followed  the  strangulation  of  a  por- 
tion of  bowel  through  a  hole  in  the  duplicature  of  peritoneum  belonging 
to  the  vermiform  appendix,  or  through  a  hole  in  the  suspensory  ligament 
of  the  liver,  or  in  the  broad  ligament  of  the  uterus.  Meso-colic  rupture 
is  probably  a  congenital  malformation.     Three  cases  of  it  are  recorded  in 

'  Pathological  Anatomy  :  Sydenham  Society's  Translation,  vol.  ii. 


OBSTEUCTION   OF   THE   BOWELS.  31 

the  "  Transactions  of  the  Pathological  Society  ; "  and  in  each  of  them 
nearly  the  whole  mass  of  small  intestines  was  contained  in  a  large  pouch 
of  the  transverse  meso-colon,  or  in  the  mesentery  of  the  transverse  and 
descending  colon.  In  two  of  them  death  was  due  to  disease  independent 
of  the  rupture;  in  the  third,  recorded  by  Dr.  Peacock,  the  patient  died  of 
strangulation.  There  is  probably  no  part  of  the  peritoneal  surface  to 
which  bands  capable  of  producing  strangulation  may  not  be  attached; 
but  there  are  certain  structures  and  certain  conditions  of  parts  with  which 
they  are  specially  apt  to  be  connected.  Thus,  the  vermiform  appendix 
often  becomes  adherent  to  neighboring  structures,  such  as  the  mesentery, 
small  intestine,  colon  and  ovary,  forming  a  kind  of  loop;  thus,  too,  diver- 
ticula of  the  lower  extremity  of  the  ileum  become  attached,  with  a  similar 
result,  usually  by  the  apex,  either  to  the  mesentery  or  some  other  neigh- 
boring part,  or  are  prolonged  to  the  umbilicus  in  the  form  of  a  cord  (a 
remnant  of  foetal  life).  Again,  bands  producing  strangulation  are  often 
joined  to  the  mesentery,  or  the  parts  concerned  in  old  ruptures,  and  often 
to  the  pelvic  organs,  more  particularly  the  uterus.  Fallopian  tubes,  and 
ovaries.  It  may  here  be  noted  also  that  strangulation  is  not  very  infre- 
quently produced  by  the  slipping  of  a  loop  of  intestine  under  the  lower 
edge  of  the  mesentery  (unusually  elongated),  of  a  portion  of  bowel  hang- 
ing low  into  the  pelvis,  or  even  under  the  pedicle  of  an  ovarian  or  uterine 
tumor.  Finally,  there  are  rare  cases  of  internal  strangulation,  in  which 
the  bowel  protrudes  into  a  lacerated  bladder  or  uterus,  or  into  a  perforated 
bowel,  or  through  the  diaphragm.  Cases  also  are  occasionally  met  with 
in  which  there  is  a  free  communication,  generally,  if  not  always  congenital, 
between  the  peritoneum  and  pericardium,  or  one  of  the  pleurae. 

The  small  intestine  is  much  more  frequently  strangulated  than  the 
large ;  and  of  the  large  intestine  the  regions  most  liable  to  this  accident 
are  those  which  are  most  movable,  namely,  the  caecum  and  sigmoid  flex- 
ure. Internal  strangulation  occurs  at  any  age;  generally,  however,  above 
thirty;  but  strangulation  in  connection  with  the  appendix  vermiformis,  or 
a  diverticulum  happens  most  frequently  in  comparatively  early  life,  the 
average  age  being,  according  to  Dr.  Brinton,  twenty-two  years;  further, 
strangulation  from  diverticula  and  from  lacerated  mesentery  is,  according 
to  all  authorities,  far  more  common  among  males  than  females.  It  has 
already  been  pointed  out  that  there  is  a  very  important  relation  between 
peritoneal  bands  and  the  sacs  of  old  herniae,  and  in  females  between  such 
bands  and  the  pelvic  organs. 

(b)  Sy^nptoms. — The  symptoms  of  internal  strangulation  are  identical 
with  those  of  ordinary  strangulated  hernia,  and  so  like  those  which  have 
been  described  as  the  symptoms  of  the  severer  form  of  enteritis  that  there 
is  no  occasion  to  give  here  any  special  account  of  them.  It  need  scarcely 
be  added  that  they  differ  essentially  from  those  of  stricture  and  of  com- 
pression of  the  bowel,  in  the  facts  that  they  are  always  sudden  in  their 
origin  and  acute  in  their  severity  and  progress,  and  always  end  fatally 
(if  the  stricture  be  not  relieved)  within  a  few,  rarely  more  than  five  or 
six,  days. 

(c)  Treatment.  —  As  regards  the  general  management  and  medical 
treatment  of  these  cases,  nothing  can  be  added  to  what  has  already  been 
laid  down  in  reference  to  enteritis.  But  whenever  the  diagnosis  of  an 
internal  strangulation  has  been  made,  it  must  of  necessity  become  a  ques- 
tion whether  an  operation  should  be  performed  with  the  object  of  reliev- 
ing it.  There  can  be  no  doubt,  of  course,  that  the  liberation  of  a  portion 
of  bowel  strangulated  by  any  of  the  various  causes  above  enumerated 


33  DISEASES    OP   THE   INTESTINES   AND   PERITONEUM. 

ought  ccBterls  paribus  to  be  attended  with  as  good  results  as  the  division 
of  the  stricture  in  ordinary  cases  of  strangulated  hernia;  but  there  is  also 
no  doubt  that  operations  performed  with  that  intention  have  not  on  the 
whole  afforded  any  encouraging  results.  When,  however,  we  consider 
that  although  typical  cases  of  the  different  kinds  of  intestinal  obstruction 
may  really  present  characteristic  peculiarities  of  symptoms,  it  is  yet  for 
the  most  part  exceedingly  difficult  in  practice  to  discriminate  the  cases 
that  come  before  us,  and  that  therefore  operations  must  comparatively 
often  be  performed  where  from  the  nature  of  things  they  must  be  useless; 
and,  further,  that  while  even  in  the  case  of  the  operation  for  ordinary 
strangulated  hernia  its  early  performance  is  generally  essential  for  its 
success,  in  the  case  of  internal  strangulation  the  operation,  if  performed 
at  all,  is  almost  always  delayed  until  a  late  stage  in  the  disease;  it  is  not 
hard  to  understand  why  so  little  success  has  attended  the  operative  treat- 
ment of  the  cases  under  consideration.  A  sufficient  number  of  operations 
has,  however,  been  successful  to  justify  us  in  laying  it  down  as  a  rule, 
first,  that  in  every  case  in  which  we  have  come  to  the  conclusion  that  a 
patient  is  suffering  from  internal  strangulation,  an  operation  should  be 
performed  for  its  relief;  secondly,  that  in  all  cases  in  which  we  think  it 
not  improbable  that  such  a  strangulation  exists,  the  patient  should  not  be 
allowed  to  die  without  an  exploratory  operation  having  been  effected  or 
at  least  proposed. 

(d)  Note  on  Torsion  or  Twisting  of  Bowel. — There  is  a  class  of  cases, 
far  from  uncommon,  which  may  be  conveniently  adverted  to  here.  They 
are  cases  of  what  is  called  "Torsion"  or  "Twisting"  of  the  bowel.  It 
has  already  been  shown  that  fatal  obstruction  to  the  passage  of  fjecal 
matters  along  the  bowel  may  be  caused,  or  appear  to  be  caused,  by  the 
formation  of  some  abnormal  abrupt  bend,  or  twist,  in  connection  usually 
with  external  adhesions.  In  these  cases,  however,  death  is  caused,  as  in 
stricture  or  compression  from  without  (with  which  last  I  have  classed 
them),  by  obstruction  alone.  But  in  the  cases  now  to  be  considered,  the 
twisted  portion  of  bowel  becomes  the  seat  of  enteritis,  and  death  results 
speedily,  with  the  symptoms  of  enteritis  rather  than  those  of  obstruction. 
The  cases,  indeed,  clinically  seem  to  be  undistinguishable  from  cases  of 
enteritis  or  internal  strangulation.  The  onset  of  the  disease  is  sudden, 
the  symptoms  acute  and  severe,  and  the  supervention  of  collapse  and 
death  speedy.  And  on  examination  after  death  there  is  found  a  lengt'i 
of  bowel  greatly  dilated  and  black  with  congestion  and  inflammation,  if 
not  gangrene,  no  strangulation,  at  least  no  strangulation  in  the  ordinary 
sense  of  the  word,  but  instead,  a  remarkable  twisting  of  the  inflamed 
tract  of  bowel  with  its  mesentery,  by  which  twisting  it  is  supposed  that 
the  vessels  leading  to  and  from  the  part  have  become  obstructed.  Such 
twisting,  associated  with  inflammatory  mischief,  is  sometimes  observed  in 
the  small  intestine;  but  it  is  far  more  commonly  met  witli  in  connection 
with  the  larger  bowel,  and  especially  with  the  sigmoid  flexure  and  caecum. 
If  these  cases  be  really,  as  is  generally  believed,  cases  in  which  strangula- 
tion of  the  bowel  is  produced  by  the  twisting  of  itself  and  its  mesentery, 
they  naturally  fall  under  the  head  of  internal  strangulation,  with  which, 
as  has  been  pointed  out,  their  symptoms  and  progress  ally  them.  I  must 
confess,  however,  that  I  have  a  strong  inclination  to  believe  that  most,  if 
not  all,  recorded  cases  of  this  affection  are  essentially  cases  of  enteritis, 
and  that  the  twisting  is  a  secondary  phenomenon  only.  It  is  not  very 
easy  to  see  how  a  portion  of  bowel,  unless  its  position  be  altered  and  its 
movements  interfered  with  bv  adhesions  (and  certainly  in  many  of  the 


OBSTRUCTION    OF   THE    BOWELS.  33 

cases  no  adhesions  whatever  are  observed),  can  become  so  twisted  by  any 
movements  of  its  own,  or  even  by  the  pressure  of  surrounding  healthy 
parts,  as  to  be  either  strangulated  or  incapable  in  virtue  of  its  own  peris- 
taltic movements  of  recovering  its  normal  position;  but  it  is  easy  to  see 
tliat  an  inflamed  and  paralyzed  portion  of  intestine,  heavy  with  accumu- 
lated contents,  dilated  to  many  times  its  normal  bulk,  and  forming  a 
doughy,  inelastic,  inert  mass,  may  under  certain  conditions  by  its  mere 
weight  subside  from  its  normal  site,  or  be  pushed  aside  by  the  pressure  of 
the  actively  vital  parts  around  it,  and  so  be  made  to  assume  a  position 
and  form  suggesting  the  generally  received  explanation  of  the  sequence 
of  events. 

V.  Impaction  of  Foreign  Bodies. — It  has  already  been  pointed  out 
that  mere  ordinary  intestinal  contents,  no  matter  how  unwholesome,  how 
indigestible,  or  how  imperfectly  comminuted  the  ingesta  from  which  they 
are  derived  may  be,  very  rarely  indeed  cause  by  their  accumulation  per- 
manent intestinal  obstruction;  yet  it  is  not  improbable  that,  according  to 
the  ordinary  belief,  undigested  masses  of  food  do  sometimes,  in  their  pas- 
sage along  the  small  intestine,  move  with  difficulty,  or  become  tempo- 
rarily impacted,  and  so  produce  pain  and  sickness,  and  even  symptoms  of 
obstruction.  Dr.  Brinton  describes  a  case  of  this  kind,  in  which  he 
asserts  that  he  distinctly  traced  by  palpation  a  mass  of  half-chewed  fil- 
berts in  its  passage  (lasting  two  days)  along  the  small  intestine. 

(a)  Pathology. — Foreign  bodies,  indeed,  of  comparatively  small  size, 
such  as  coins,  fragments  of  bone,  teeth,  marbles,  plum-stones  and  cherry- 
stones, generally  pass  along  the  healthy  intestine  without  causing  any 
material  inconvenience;  and  occasionally  even  pointed  bodies — pins  and 
the  like — prove  equally  innocuous.  They  are  all,  however,  a  source  of 
serious  danger  in  the  presence  of  strictures,  above  which  they  usually 
become  arrested,  or  in  which  they  may  become  lodged.  The  smaller  ones 
among  them  may  lead  also  to  serious  results  by  slipping  into  a  diverticu- 
lum, or  into  the  vermiform  appendix;  and  those  which  are  pointed  are 
apt  to  perforate  the  intestinal  wall,  and  thus,  escaping  into  the  peii- 
toneal  cavity,  to  set  up  fatal  peritonitis,  or,  escaping  into  the  surrounding 
tissues,  to  provoke  suppuration  there.  In  the  latter  case,  the  foreign 
body  sometimes  emerges  through  the  abdominal  parietes,  sometimes 
(when  it  perforates  the  rectum)  is  the  cause  of  anal  fistula. 

Insoluble  matters,  in  the  form  of  powder,  or  in  a  fibrous  state,  which 
under  ordinary  conditions  may  be  swallowed  with  perfect  impunity,  occa- 
sionally, after  having  been  taken  habitually  in  large  quantities  and  for 
long  periods,  are  found  to  have  been  gradually  deposited  from  the  fascal 
contents  of  the  bowels,  and  to  have  concreted  into  hard  masses.  These 
are  sometimes  round  or  ovoid,  and  may  then  be  termed  intestinal  calculi, 
and  sometimes  form  casts  of  the  portion  of  gut  in  which  they  lie.  The 
former  are  probably  always  found  in  the  large  intestine:  the  latter  rarely, 
if  ever,  occupy  any  other  position  than  the  rectum.  Among  substances 
which  thus  occasionally  form  concretions,  are  sesquioxide  of  iron,  carbon^ 
ate  of  magnesia,  insufficiently  cooked  starch,  and  oat-hair  derived  from, 
oat-cake  and  other  articles  of  food  made  from  oats. 

Amongst  cases  of  exceptional  rarity  may  be  included  those  which  are 
here  and  there  recorded  of  persons  who  have  been  in  the  habit  of  swallow- 
ing knives,  or  pins,  or  string,  or  hair,  or  cocoa-nut  fibres;  things  which,, 
from  various  causes,  are  somewhat  difficult  of  transmission,  and  which, 
with  the  constant  additions  which  are  made  to  them  gradually  form  accu- 
luulaiions  or  masses,  which  sometimes  attain  very  considerable  dimen»- 
3 


84  DISEASES    OF   THE    INTESTINES    AND    PERITONEUM. 

sioiis,  and  may  then  easily  be  distinguished  through  the  abdominal  walls. 
These  are  generally  found  to  occupy  more  particularly  the  stomach  and 
upper  part  of  the  small  intestine,  and,  when  composed  of  fibrous  sub- 
stances, take  the  shape  of  the  cavit}'  in  which  they  have  formed.  Their 
presence  causes  gradual  dilatation  of  the  part  in  which  they  are  lodged, 
then  congestion,  intlammation,  and  ulceration,  and  finally,  either  perfora- 
tion into  the  peritoneal  cavity,  or  complete  obstruction.  It  is  remarkable, 
however,  how  long  a  period  often  elapses  before  such  cases  terminate  in 
death,  and  how  little,  comparatively,  of  distress  or  even  inconvenience  the 
patient  often  experiences  previous  to  the  supervention  of  fatal  symptoms. 
But  the  usual  cause  of  fatal  impaction,  and  that  which  comes  more 
especially  within  the  scope  of  the  present  article,  is  tbe  escape  of  a  largo 
gall-stone  from  the  gall-bladder  into  the  small  intestine.  The  gall- 
stones here  referred  to  are  not  those  which  so  commonly  slip  from  the 
gall-bladder  into  the  cystic  duct,  and  thence  into  the  common  duct,  and 
thence  (if  they  do  not  become  firmly  fixed  there)  into  the  duodenum  ;  for 
although  these  cause  grave  symptoms  enough  so  long  as  they  are  retained 
within  the  biliarj'  passages,  they  cease,  as  a  rule,  to  cause  any  ill  efifects 
so  soon  as  they  have  gained  an  entrance  into  the  bowel  ;  their  compara- 
tive smallness  allowing  them  to  pass  along  the  intestines  and  to  escape 
with  the  faeces,  just  as  a  plum-stone  or  a  cherry-stone  might  do.  The 
biliary  concretions  which  become  impacted  in  the  bowel  are  single  stones, 
or  masses  of  coherent  stones,  of  considerable  bulk,  varying,  at  a  rough 
estimate,  from  three  to  four  inches  in  circumference,  and  from  one  inch  to 
two,  three,  or  even  four  inches  in  length ;  in  the  former  case  presenting 
more  or  less  of  the  ordinary  cuboidal  form,  in  the  latter  case  forming  a 
more  or  less  complete  cast  of  the  gall-bladder.  It  is  obviously  scarcely 
possible  that  concretions  of  this  magnitude  can  escape  from  the  gall-blad- 
der joerv/flw  wafwraic^y  and  there  is  reason  to  believe  that  in  all  cases 
where  a  careful  examination  has  been  made,  an  ulcerated  opening  has 
been  discovered,  by  which  the  cavity  of  the  gall-bladder  and  that  of  the 
duodenum  were  in  tolerably  free  communication,  and  through  which  the 
concretion  had  obviously  escaped  from  its  bed.  When  a  large  calculus 
has  thus  got  into  the  duodenum,  it  seems  to  be  carried  on  with  the  other 
contents  of  the  bowel  by  means  of  the  ordinary  peristaltic  movements. 
But  its  mere  bulk  prevents  it  from  moving  readily:  besides  which  it  pro- 
vokes by  its  shape  and  hardness,  as  well  as  by  its  bulk,  some  irritation,  if 
not  inflammation,  of  the  mucous  surface  over  which  it  passes,  and  more 
or  less  spasmodic  contraction  of  the  muscular  tissue  which  surrounds  it. 
It  hence  continues  to  progress  irregularly,  now  moving  slowly,  now  com- 
ing to  a  standstill,  impelled  onwards  by  the  vis  d  tergo,  checked  in  its  pas- 
sage by  the  spasmodic  contraction  of  the  portion  of  bowel  which  embraces 
it,  and  by  the  comparatively  empty  and  contracted  state  of  that  which  is 
below  it,  and  causing  as  it  descends  more  and  more  mischief  to  the 
mucous  surface,  until  finally  it  becomes  impacted,  sometimes  in  the  je- 
junum, sometimes  in  the  ileum,  and  not  unfrequently  just  above  the  ileo- 
caecal  valve.  Then  all  the  effects  of  complete  obstruction,  conjoined  with 
those  of  intense  enteritis,  supervene  ;  the  bowel  below  becomes  empty,  that 
above  distended  with  accumulated  contents,  and  generally  more  or  less 
inflamed,  while  at  the  seat  of  obstruction  and  in  its  immediate  neighbor- 
hood the  inflammation  becomes  intense,  extending  speedily  to  the  peri- 
toneal surface,  and  ends  not  rarely  in  gangrene  and  in  perforation.  Gall- 
stones rarelv,  if  ever,  become  lodged  in  the  ca;cum,  colon,  or  any  other 
part  of  the  large  intestine. 


OBSTRUCTION   OF   THE    BOWELS.  35 

Gall-stones  are  a  product  of  the  later  period  of  life  ;  and  hence  obstruc- 
tion by  gall-stones  can  only  be  looked  for  at  an  advanced  age.  It  occurs 
indeed  rarely  before  the  fiftieth  year,  and,  it  may  be  added,  much  more 
frequently  in  women  than  in  men.  Dr.  Brinton  estimates  the  average 
age  of  its  occurrence  at  53^  years,  and  that  it  occurs  four  times  as  fre- 
quently in  women  as  in  the  opposite  sex. 

(b)  Sytn2)toms  and  Treatment. — The  symptoms  which  indicate  ob- 
struction of  the  bowels  by  a  gall-stone  are  as  nearly  as  possible  identi- 
cal with  those  which  attend  internal  strangulation  or  enteritis.  The  cases 
themselves  are,  however,  amongst  the  most  violent  in  their  symptoms  and 
the  most  rapid  in  their  course  of  all  cases  of  intestinal  obstruction  ;  con- 
ditions which  result  partly  from  the  intensity  of  the  inflammation  which 
attends  them,  partly  from  the  fact  that  the  obstruction  is  almost  without 
exception  situated  in  the  small  intestine,  and  often  high  up  in  it.  Dr. 
Brinton  calculates  their  average  duration  at  five  days.  There  are  two  or 
three  circumstances  which  may  afford  more  or  less  assistance  in  the  dis- 
crimination of  obstructions  by  gall-stones  :  such  are,  first,  the  age  and 
sex  of  the  person  attacked;  second,  the  possibility  in  certain  cases  of 
discovering  by  palpation  the  presence  of  a  gall-stone  (that  is  to  say,  of  a 
solid  mass)  in  the  bowels,  and  even  of  tracing  in  some  degree  its  prog- 
ress; and  third,  the  occurrence  of  precursory  symptoms  due  to  the  escape 
of  the  gall-stone  from  the  gall-bladder,  and  to  its  presence  in  the  bowel 
in  the  interval  between  this  escape  and  its  final  impaction.  It  must  not 
be  forgotten,  however,  that  in  practice  not  only  do  we  often  fail  in  these 
cases  to  recognize  a  lump,  or  to  obtain  a  history  of  premonitory  symp- 
toms; but  that  we  may  have  both  a  lump  and  a  history  in  cases  where 
the  symptoms  are  wholly  independent  of  the  presence  of  a  biliary  calcu- 
lus or  other  foreign  body.  There  does  not  appear  to  have  been  observed 
any  connection  between  ordinary  "  attacks  of  gall-stones,"  and  the  affec- 
tion now  under  consideration.  This  circumstance,  however,  is  not  re- 
markable, when  it  is  borne  in  mind  that  gall-stones  which  escape  by  the 
normal  route  must  necessarily  be  small,  and  that  the  escape  of  one  such 
stone  makes  the  way  of  escape  for  others  that  may  be  in  the  bladder 
comparatively  easy,  whereas  those  which  cause  intestinal  obstructions  are 
always  large,  and  are  often  casts  of  the  gall-bladder. 

It  may  be  added  here,  that  not  all  large  gall-stones  cause  death,  after 
their  entrance  into  the  bowel,  by  obstructing  it.  They  sometimes  become 
encysted  in  a  pouch  which  they  have  themselves  been  instrumental  in 
producing.  Dr.  George  Harley'  records  a  case  in  which  a  gall-stone 
became  thus  lodged  in  the  duodenum.  Sometimes,  again,  they  escape 
per  anum.  It  is  of  course  impossible  to  lay  down  any  law  as  to  the  limits 
of  size  beyond  which  it  is  impossible  for  a  solid  body  to  pass  through  the 
ileo-cjecal  orifice;  but  there  are  good  grounds  to  suspect  that  in  most 
cases  where  large  calculi  have  been  voided,  they  have  passed  by  ulceration 
directly  from  the  gall-bladder  into  the  colon. 

No  distinction  need  be  made  between  the  treatment  of  cases  of  ob- 
struction by  gall-stones,  and  that  of  cases  of  enteritis. 

VI. — Intussusception. — {a)  Pathology. — By  intussusception  is  meant 
the  prolapse  or  slipping  of  a  tuck  of  intestine  into  the  cavity  of  the  por- 
tion of  intestinal  tube  immediately  below  it,  wherewith  it  is  continuous. 
In  consequence  of  this,  we  find  the  normal  course  of  the  intestine  intev- 
rupted  by  a  kiijd  of  knot,  in  which  three  successive  lengths  of  bowel  lie 

'  Path.  Soc.  Trans.,  vol.  viii. 


SQ  DISEASES   OP   THE   INTESTINES    AND   PERITONEUM. 

almost  concentrically  one  within  the  other;  the  innermost  length  being 
formed  by  the  portion  of  bowel  which  has  descended,  the  outermost 
length  consisting  of  the  portion  of  bowel  into  which  the  descent  has 
occurred,  the  middle  or  intermediate  length  being  the  portion  of  bowel 
which  unites  the  upper  extremity  of  the  one  with  the  lower  extremity  of 
the  other,  and  lies  therefore  in  an  inverted  and  everted  position  between 
them.  The  mesentery  of  the  inner  two,  or  included,  lengths  of  bowel  is 
in  their  descent  necessarily  dragged  down  with  them  into  the  pouch  which 
they  form,  and,  by  the  unilateral  traction  which  it  exerts,  necessarily 
gives  to  their  double  tube  a  curvature  of  which  the  concavity  corresponds 
to  the  line  of  mesenteric  attachment;  so  that  the  lower  orifice  of  the 
invaginated  portion  of  bowel,  instead  of  lying  in  the  axis  of  the  contain- 
ing bowel,  faces  and  rests  upon  some  portion  of  its  circumference.  The 
several  layers  are  generally  more  or  less  convoluted  (with  convolutions 
running  transversely)  or  twisted:  but  this  convolution  or  twisting  is 
always  most  marked  in  the  middle  tube.  The  immediate  effects  of  intus- 
susception are,  first,  more  or  less  obstruction  to  the  passage  of  the  intes- 
tinal contents,  and,  second,  more  or  less  obstruction  to  the  return  of 
blood  from  the  inner  two  cylinders  of  bowel  involved,  to  which  the 
stretched  and  constricted  portion  of  mesentery  belongs.  It  is  obvious 
that  the  innermost  tube  must  be  pretty  tightly  compressed  by  the  tubes 
external  to  it,  a  condition  which  must  be  much  increased  by  the  swelling 
of  parts  which  speedily  takes  place;  especially  it  is  always  found  to  be 
very  tightly  girded  at  its  point  of  entrance  by  the  tumid  ring  formed  at 
the  junction  of  the  outer  two  layers.  Nevertheless,  the  obstacle  which 
an  intussusception  opposes  is  often  incomplete,  for  it  is  certain  that  in  a 
good  many  cases  faecal  matters,  not  always  in  small  quantities,  pass 
through  it  pretty  constantly:  a  circumstance  due,  in  part,  to  the  efficiency 
of  the  contractile  force  of  the  bowel  above  to  squeeze  a  portion  of  its  con- 
tents into  the  narrowed  tube  below,  but  chiefly  to  the  retention  still  of 
contractile  power  in  the  affected  portions  of  bowel.  Very  soon  after 
the  occurrence  of  intussusception  all  the  tissues  of  the  inner  two  tubes, 
internal  to  the  serous  membrane,  become  black  or  nearly  so  with  conges- 
tion and  escape  of  blood  into  their  substance,  and  the  serous  surface  con- 
sequently assumes  a  more  or  less  deep  slate-color.  At  the  same  time, 
partly  from  the  accumulation  of  blood,  partly  from  the  transudation  of 
serum,  their  walls  become  very  greatly  swollen,  and  sanguinolent  serum 
or  blood  becomes  effused  from  the  mucous  membrane,  and  may  be  found 
collected  both  in  the  interval  between  the  opposed  mucous  surfaces  of  the 
outer  two  layers  of  the  intussusception,  in  the  central  canal,  and  in  the 
bowel  below  the  seat  of  disease.  At  a  somewhat  later  period  coagulable 
lymph  is  secreted  from  the  opposed  serous  surfaces  of  the  middle  and 
internal  layers,  and  these  become  consequently  agglutinated  in  their  whole 
length.  The  two  invaginated  tubes  remain  sometimes  for  a  long  while 
in  the  condition  above  described,  but  often  ere  long  become  gangrenous, 
and  then,  if  the  patient  survive  sufficiently  long,  separate  from  their  at- 
tachments and  become  discharged  ^jer  atnim. 

Intussusception  is  doubtless  always  an  accident  of  sudden  occurrence 
in  connection  with  some  violent  spasmodic  action  of  the  portion  of  bowel 
which  becomes  prolapsed.  It  seems  certain,  however,  that  there  must  be 
some  associated  conditions  which  concur  with  spasmodic  action  in  pro- 
ducing it.  A  wave  of  peristalsis  is  made  up  of  two  distinct  elements: 
first,  the  contraction  of  the  longitudinal  fibres  which  shortens  the  bowel 
and  dilates  it,  and  (since  it  travels  from  above  downwards)  draws  the  por- 


OBSTRUCTION   OF   THE   UOWELS.  37 

tion  of  bowel  below,  in  which  the  contraction  is  commencing,  towards 
the  portion  of  bowel  above,  in  which  the  contraction  is  completed;  second, 
immediately  following  upon  this,  the  contraction  of  the  circular  fibres 
which  narrows  the  bowel  and  elongates  it,  and,  in  elongating  it,  projects 
the  narrowing  segment  forward.  Now,  it  is  obvious  that  in  these  two 
associated  elements,  namely,  the  dilatation  of  one  segment  of  the  bowel 
with  a  tendency  in  its  lower  part  to  be  drawn  upwards,  and  the  narrowing 
of  the  segment  of  bowel  immediately  above  it  with  a  tendency  in  its  lower 
end  to  be  pushed  forwards,  we  have  conditions  which,  with  very  slight 
modification  or  exaggeration,  might  permit  of  the  protrusion  of  the  nar- 
rowing segment  above  into  the  dilated  segment  below.  The  circumstances 
which  either  alone  or  in  combination  might  have  this  effect  would  seem 
to  be:  first,  the  presence  of  much  gaseous  matter  leading  momentarily  to 
excessive  distention  of  the  portion  of  bowel  into  which  the  wave  of  circu- 
lar contraction  is  advancing;  second,  immobility  from  whatever  cause  of 
this  distended  portion  of  bowel,  so  that  it  is  not  pushed  on  bodily  by  the 
elongation  of  the  narrowing  segment  above;  and  third,  the  occurrence  at 
this  moment  of  some  violent  muscular  eifort,  involving  the  action  of  the 
muscular  parietes  of  the  abdomen.  The  efficiency  of  these,  or  of  equiva- 
lent circumstances,  in  causing  descent  of  the  bowel,  is  shown  in  the  cases 
of  prolapse  of  the  rectum,  and  prolapse  of  bowel  through  an  artificial 
anus;  as  well  as  in  the  most  common  case  of  intuaiutception,  namely, 
that  in  which  the  extremity  of  the  ileum  slips  into  the  cavity  of  the  ce- 
cum. It  is  supposed  that  the  presence  of  lumbrici  occasionally  deter- 
mines the  occurrence  of  intussusception,  and  with  more  reason  that  the 
presence  of  a  large  polypus  has  this  effect.  It  may  be  remarked,  how- 
ever, that  in  some  of  the  recorded  examples  of  concurrence  of  intussus- 
ception and  polypus,  the  intussusception  and  polypus  have  been  at  a 
distance  from  one  another. 

In  every  case  an  intussusception  must  obviously  in  the  first  instance 
involve  a  short  length  of  bowel  only;  but  for  the  most  part  it  rapidly  in- 
creases in  size  owing  to  the  active  peristaltic  movements  of  the  several 
segments  engaged.  This  increase  takes  place  partly  by  the  prolapse  of 
more  and  more  bowel  from  above,  but  chiefly  by  the  involution  of  more 
and  more  of  the  outer  layer.  In  most  cases  indeed,  if  not  in  all,  the  parts 
which  in  the  first  instance  formed  the  margins  of  the  lower  orifice  of  the 
invaginated  portion  of  bowel  continue  to  form  that  orifice,  no  matter  what 
length  the  intussusception  may  ultimately  attain.  The  growth  of  the  in- 
nermost tube  therefore  is  the  result  simply  of  the  descent  of  more  and 
more  bowel  from  above,  while  the  growth  of  the  middle  tube  takes  place 
at  the  expense  of  the  outermost  tube  only,  in  consequence  of  its  gradual 
inversion. 

The  length  of  bowel  involved  in  an  intussusception  varies  within  wide 
limits.  Including  in  our  measurement  the  inner  two  layers  only,  or  those 
which  constitute  the  intussuscepted  portion,  the  length  varies  from  two  to 
three  inches  up  to  three  or  four  feet.  A  case  indeed  is  quoted  by  Dr. 
Peacock,'  in  which,  judging  from  the  combined  lengths  of  portions  which 
escaped  from  time  to  time  per  anum,  there  is  reason  to  believe  the  in- 
vagination had  comprised  twelve  feet  of  bowel. 

Intussusception  is  rather  more  than  twice  as  common  in  males  as  in 
females,  both  before  and  after  puberty.     It  occurs  at  all  periods  of  life, 


'  Path,  Trans,  vol.  xv. 


88  DISEASES    OF   TKE   INTESTINES    AND   PERITONEUM. 

but  is  singular,  amongst  obstructive  diseases,  in  the  frequency  with  which 
it  affects  young  children. 

Intussusception  is  not  very  infrequently  met  with  after  death  in  per- 
sons (children  and  adults)  in  whom  during  life  there  had  been  no  reason 
to  suspect  its  presence,  who  have  had  no  symptoms  which  can  be  attributed 
to  it,  and  who  have  died  of  some  totally  different  disease.  In  these  cases 
the  intussusceptions  are  always  found  in  the  small  intestine — sometimes, 
indeed,  two  or  three  are  met  with  in  the  same  case — they  are  generally 
not  above  an  inch  or  two  long,  are  easy  of  reduction,  and  present  little  or 
no  oedema  or  congestion.  It  is  not  impossible,  as  has  often  been  sug- 
gested, that  similar  slight  intussusceptions  take  place  occasionally  during 
good  health,  and  having  caused  symptoms  of  more  or  less  severity,  undergo 
spontaneous  evolution  with  restoration  of  the  integrity  of  the  bowel.  In- 
tussusceptions which  prove  fatal  may  occur  in  almost  any  part  of  the  in- 
testinal canal,  but  they  occur  in  different  regions,  with  very  different 
degrees  of  frequency.  Out  of  100  fatal  cases  (according  to  Dr.  Brintou's 
figures),  4  are  jejunal,  28  iliac,  56  ileo-caecal  (that  is,  involving  the  cecum 
together  with  the  ileum  and  colon),  and  12  colic,  or  originating  in  and  in- 
volving the  colon  only.  It  must  be  noticed,  however,  that  recoveries 
with  separation  of  the  intussuscepted  bowel  are  much  more  numerous  in 
those  cases  in  which  intussusception  occurs  in  the  small  intestine  than  in 
those  cases  in  which  it  involves  the  colon,  a  fact  which  renders  it  more 
than  probable  that  the  jejunal  and  iliac  varieties  form  a  larger  proportion 
of  the  whole  number  of  cases  of  intussusception  than  Dr.  Brinton's  figures 
might  lead  us  to  believe.  It  may  be  added,  moreover,  that  intussusception 
occasionally  begins  in  tlie  rectum,  of  which  Dr.  H.  Fagge  quotes  an  ex- 
ample; and  that  prolapsus  of  the  rectum,  which  in  some  cases  involves 
the  descent  of  the  muscular  wall  together  with  that  of  the  mucous  mem- 
brane, is  under  these  latter  circumstances  a  true  intussusception. 

Jejunal  or  iliac  intussusception  is  met  with  generally,  if  not  exclusively, 
in  adults.  The  average  age  of  its  occurrence  is,  according  to  Dr.  Brinton, 
34'6  years.  It  is  here  that  the  peculiar  curvature  of  the  invaginated  part, 
due  to  the  traction  of  the  mesentery,  is  most  observable;  and  it  is  here, 
owing  probably  to  the  comparative  narrowness  of  the  tube  into  which  the 
invaginated  portion  of  bowel  descends,  that  strangulation  and  congestion 
are  most  speedy  and  most  intense,  and  that  sloughing  and  separation  of 
the  strangulated  part  are  consequently  most  frequent.  The  length  of 
bowel  engaged  in  this  form  of  invagination,  although  it  may  be  as  much 
as  several  feet,  is  generally  less  than  in  intussusceptions  involving  the 
large  intestine. 

Ileo-caecal  invagination  occurs  largely  amongst  young  children,  includ- 
ing babes  of  a  few  months  old.  Dr.  Brinton  considers  that  half  the  total 
number  of  cases  are  in  children  under  seven  years  of  age;  and  that  tlie 
mean  age  of  those  affected  by  it  is  18'57  years.  It  begins  with  the  descent 
into  the  cavity  of  the  cnscum  of  the  lips  of  the  ileo-coecal  orifice,  which 
form  henceforth  the  lower  extremity  of  the  invagination.  As  this  in- 
creases, the  descending  ileo-coecal  orifice  drags  down  with  it  more  and 
more  of  the  ileum  to  form  the  central  tube,  and  iji verts  first  the  caecum, 
and  then  a  gradually  increasing  quantity  of  the  colon,  to  form  the  inverted 
or  middle  layer;  and  still  descending,  finally  in  some  cases  reaches  the 
rectum  or  even  protrudes  from  the  anus.  It  may  be  added  that  the  orifice 
of  the  vermiform  process  necessarily  retains  its  position  relatively  to  the 
ileo-c«cal  orifice,  and  that  the  process  itself  therefore  lies  at  tlie  bottom 
of  the  pouch  between  the  inner  and  middle  tubes.     In  ileo-ca;cal  invagi- 


OBSTRUCTION    OF   THF   BOWELS.  39 

nation,  which  is  that  in  which  the  greatest  length  of  bowel  may  be  en- 
gaged, there  is  generally  much  transverse  folding  of  the  several  layers  of 
intestine  which  form  it,  especially  of  the  middle  layer,  which  is  also  often 
much  convoluted  or  twisted.  Strangulation  is  comparatively  much  more 
rare  here  than  in  intussusception  limited  to  the  small  intestine,  doubtless 
because  of  the  comparative  roominess  of  the  colon :  and  in  a  proportionate 
degree  sloughing  and  discharge  of  the  invaginated  tissues  are  necessarily 
uncommon. 

A  variety  of  ileo-cascal  invagination  of  very  rare  occurrence  is  that  in 
which  the  lower  extremity  of  the  small  intestine  descends  into  the  cascum 
tlirough  the  ileo-caecal  orifice;  the  lips  of  the  orifice  not  necessarily  de- 
scending with  it.  Strangulation  in  this  case  is  said  to  be  generally  sud- 
den and  complete,  in  consequence  of  the  tightness  with  which  the  prolapsed 
bowel  is  gripped  by  the  valve.  Colic  and  rectal  intussusceptions  are  com- 
paratively infrequent,  and  differ  little,  except  in  the  parts  involved,  from 
the  ileo-caecal  form  of  the  affection. 

If  the  patient  survive  sufficiently  long  after  the  formation  of  an  intus- 
susception, events  take  place  in  connection  with  it  which  have  already 
been  briefly  indicated.  The  peritoneal  inflammation  which  by  its  products 
unites  the  opposed  serous  surfaces  of  the  inner  two  layers,  may  spread  be- 
yond its  primary  seat,  and  cause  more  or  less  general  peritonitis.  Or, 
after  these  two  lawers  have  become  united,  a  further  descent  of  bowel 
may  take  place,  producing  what  is  called  a  double  intussusception — an 
intussusception,  that  is  to  say,  in  which  the  bowel  above  has  slipped  in  tlie 
form  of  a  second  invagination  into  the  canal  of  the  primary  invagination. 
Or,  again,  as  Dr.  Aitken'  shows,  the  extremity  of  the  curved  invaginated 
portion  of  bowel  may,  by  the  constant  pressure  which  it  exerts  against  the 
side  of  the  containing  tube,  cause  at  the  seat  of  pressure  ulceration  and 
perforation  of  the  intestinal  wall.  But  by  far  the  most  interesting  and 
important  event  is  the  sloughing  and  separation  of  the  included  layers  of 
bowel.  It  has  been  shown  that  almost  immediately  after  the  occurrence 
of  invagination,  these  become  oedematous,  intensely  congested,  and  iiiiij- 
trated  with  blood;  and  it  might  be  supposed  from  the  obstruction  to 
which  the  vessels  supplying  them  are  exposed,  that  their  death  must  neces- 
sarily speedily  ensue.  In  many  cases,  however,  patients  live  for  weeks, 
and  even  months,  after  the  occurrence  of  invagination,  with  no  furtlier 
changes  in  the  contained  tubes  than  those  due  to  mere  congestion  and 
swelling,  and  die  ultimately  from  the  effects  of  invagination,  the  bowel 
never,  even  to  the  last,  showing  signs  of  either  ulceration  or  gangrene. 
This  (as  has  been  stated)  happens  rarely,  if  ever,  in  intussusception  limited 
to  the  small  intestine,  but  it  is  very  common  in  the  case  of  ileo-csBcal  and 
colic  invagination.  But  in  many  instances,  and  (as  has  also  been  stated) 
far  more  frequently  in  the  case  of  the  small  intestine  than  in  that  of  the 
large,  the  deep  congestion  ends  in  the  death  of  the  intussuscepted  portion; 
wliicli  then  after  a  while,  if  the  patient  still  survives,  becomes  detached 
either  bit  by  bit  or  in  mass,  and  gradually  working  its  way  downwards 
becomes  expelled.  This  separation  generally  leaves  the  upper  extremity 
of  the  outer  tube  of  bowel  firmly  united,  at  the  neck  of  the  intussuscep- 
tion, with  the  lower  extremity  of  the  healthy  bowel  above,  the  line  of 
tmion  between  the  two  being  indicated  by  an  annular  fissure  externally,  and 
by  a  ring  of  ulceration  on  the  mucous  aspect,  attended  with  more  or  less 
diminution  of  the  calibre  of  the  intestine,  and  to  which  sometimes  por- 

■  The  Science  and  Practice  of  Medicine,  vol.  ii. 


40  DISEASES   OF   THE   INTESTINES   AND    PERITONEUM. 

tions  of  the  intussuscepted  bowel  still  living'  and  forming  a  sort  of  excres- 
cence remain  adherent.  Sometimes  at  the  moment  of  separation  of  the 
sequestrum,  the  union  between  the  upper  and  lower  parts  of  the  bowel  is 
not  complete,  and  escape  of  ffccal  matter  takes  place  into  the  peritoneal 
cavity:  and  not  unfrequently  after  the  detached  portion  of  bowel  has 
been  discharged /?c'r  anuin,  and  the  patient  promises  to  make  a  fair  recov- 
ery, the  seat  of  separation  becomes  more  and  more  narrowed,  and  ends  by 
becoming  a  tight  stricture. 

Of  thirty-live  cases  of  discharge  of  bowel  per  anum,  collected  by  Dr. 
Thomson,'  sixteen  appear  to  have  recovered  perfectly,  and  nineteen  died 
after  a  longer  or  shorter  interval;  and  out  of  nineteen  cases,  collected  by  Dr. 
Peacock,'  in  which  the  result  is  mentioned,  nine  made  a  good  recovery,  five 
still  suffered  from  symptoms  indicative  of  obstruction,  and  five  died  sub- 
sequent to  the  discharge  of  bowel,  at  intervals  varying  from  forty  days  to 
thirteen  years.  With  regard  to  the  period  at  which  the  separation  takes 
place,  it  appears,  from  Dr.  Peacock's  paper,  that  in  several  cases  bowel  was 
discharged  on  the  sixth  or  seventh  day  after  the  beginning  of  the  disease; 
that  in  most  the  discharge  took  place  before  the  twentieth  or  thirtieth  day; 
and  that  occasionally  the  bowel  was  not  passed  until  after  a  few  months 
or  even  one  year  had  elapsed.  In  one  case  fragments  of  bowel  were  ex- 
pelled at  intervals  during  a  period  of  three  years.  Lastly,  in  reference  to 
tiie  portion  of  intestine  which  thus  escapes,  it  appears  that  out  of  forty- 
three  of  the  cases  cited  by  Drs.  Thomson  and  Peacock,  in  thirty-two  it 
consisted  of  small  intestine  aloue,  and  in  eleven  only  comprised  a  part  of 
the  larger  bowel. 

{b)  The  /Symptoms  which  attend  intussusception  are  made  up  partly 
of  the  symptoms  of  intestinal  obstruction,  partly  of  those  of  enteritis;  but 
they  present  much  variety,  and  are  often  so  vague  as  to  render,  for  a  time 
at  least,  accurate  diagnosis  impossible.  There  are  nevertheless  certain 
characteristic  symptoms,  which  if  present  point  pretty  certainly  to  the  ex- 
istence of  the  lesion  in  question. 

The  commencement  of  intussusception  is  attended  with  sudden  and 
more  or  less  severe  abdominal  pain  of  a  griping  or  twisting  character, 
which  is  referred  usually  to  the  neighborhood  of  the  umbilicus.  This 
generally  ceases  after  a  short  time,  perhaps  a  few  hours,  and  then  after 
an  interval  of  comparative  or  total  ease  returns  temporarily,  and  thus 
perhaps  continues  to  recur  remittently.  There  is  not  necessarily  any 
abdominal  tenderness,  and  indeed  the  patient  frequently  finds  relief,  as 
in  colic,  by  various  contortions  of  the  body  and  by  pressure  upon  t!ie 
abdominal  parietes.  Sympathetic  vomiting  may  be  an  early  symptom, 
but  is  often  in  the  beginning  absent.  Constipation  generally  follows 
upon  the  sudden  attack  of  pain*  not  however  immediately,  for  the  bowel 
below  the  seat  of  lesion  may,  and  does  generally,  continue  to  act  upon  its 
contents  until  they  are  completely  expelled;  nor  necessarily,  because,  as 
has  been  pointed  out,  the  intussusception  does  not  in  all  cases  entirely 
prevent  the  passage  of  faecal  matters  from  above;  and  sometimes,  indeed, 
instead  of  any  tendency  to  constipation  there  is  actual  diarrhoea.  There 
is  one  peculiarity,  however,  in  connection  with  the  intestinal  evacuations, 
which  is  rarely  absent;  it  is,  that  very  soon  after  the  occurrence  of  intus- 
susception, the  blood  which  escapes  from  the  deeply  congested  mucous 
surface  of  the  invaginated  bowel  mingles  with  the  contents  of  the  bowel 
below,  and  escapes  with  them  by  stool  in  greater  or  less  abundance. 

'  Dr.  Peacock's  paper :  Path.  Trans,  vol.  iv.  p.  113.  *  Ibid, 


OBSTRUCTION    OF   TILE    BOWELS.  41 

The  syTTiptoms  which  mark  the  subsequent  progress  of  the  case  depend 
partly  on  the  situation  of  the  intussusception,  partly  on  the  degree  in  which 
the  bowel  is  strangulated.  It  has  been  shown  that  when  the  intussuscep- 
tion involves  the  large  intestine,  actual  strangulation  occurs  somewhat 
rarely,  and  the  case  tends  to  become  much  protracted.  In  this  event  the 
symptoms  are  apt  to  be  very  ill-defined:  the  paroxysms  of  pain  are  often 
slight,  and  recur  at  distant  intervals;  constipation  may  exist  at  the  begin- 
ning only,  or  may  occur  from  time  to  time,  or  it  may  never  be  distinctly 
present;  there  is  generally  more  or  less  vomiting.  As  the  case,  however, 
progresses,  the  pain  often  increases  in  severity;  the  vomiting  becomes 
more  and  more  incessant  and  possibly  stercoraceous;  the  alvine  evacua- 
tions either  continue  to  pass  or  become  re-established,  blood  and  mucous 
are  discharged  in  variable  quantities,  and  even  dysenteric  diarrhoea  comes 
on.  And  then  after  a  longer  or  shorter  period,  sometimes  after  two, 
three,  or  four  months,  the  patient,  who  has  been  gradually  getting  more 
emaciated  and  feeble,  dies  of  simple  exhaustion.  When  the  invagination 
occupies  the  small  intestine,  strangulation  is  usually  of  rapid  occurrence, 
and  its  occurrence  adds  to  the  symptoms  of  mere  intussusception  those  of 
enteritis.  The  case,  therefore,  speedily  assumes  a  very  threatening  aspect. 
Febrile  symptoms  manifest  themselves,  the  abdomen  becomes  tender,  in- 
cessant vomiting  comes  on,  and  the  bowel  becomes  obstructed,  or  at  all 
events  discharges  only  those  matters  which  the  congested  and  gangrenous 
tissues  pour  out.  Under  such  symptoms,  the  patient,  as  in  uncomplicated 
enteritis  or  internal  strangulation,  may  speedily  succumb;  but  sometimes, 
at  a  moment  when  the  disease  appears  to  be  still  progressing  unfavorably, 
the  constipated  bowel  begins  to  act,  offensive  stools  mixed  with  blood  and 
mucus  begin  to  be  discharged  with  more  or  less  tenesmus,  vomiting  di- 
minishes or  ceases,  febrile  symptoms  abate,  and  after  a  longer  or  shortc^r 
period  of  dysenteric  symptoms  a  sequestrum  is  passed  per  anum  in  the 
form  of  a  dark  foetid  gangrenous  mass. 

The  most  characteristic  features,  amongst  those  which  have  been  enu- 
merated in  the  symptomatology  of  intussusception,  are,  first,  the  sudden 
onset  of  the  malady,  with  pain  and  more  or  less  constipation  and  vomit- 
ing; and  secondly,  the  discharge  of  blood  per  anum  which  is  generally 
present  even  from  the  beginning.  But  there  is  a  third  sign,  to  which  no 
allusion  has  yet  been  made,  which  is  perhaps  of  even  greater  importance, 
namely,  the  presence  of  a  tumor.  It  can  scarcely  happen  that  any  length 
of  a  threefold  tube  of  intestine,  especially  when  its  layers,  one  or  all,  are 
congested  and  swollen,  can  be  present  without  forming  a  tumor  capable 
of  detection  by  careful  palpation  through  the  abdominal  walls,  provided 
at  least  these  be  not  too  fat  or  too  rigid,  or  the  bowels  generally  be  not 
too  much  distended  with  gas,  or  the  abdominal  tenderness  be  not  too 
great,  to  admit  of  satisfactory  examination.  The  presence  of  a  tumor 
indeed,  especially  in  the  case  of  ileo-cfecal,  or  colic,  invagination,  may  often 
be  recognized  during  life;  and  that  the  tumor  is  an  intussusception  may 
also  often  be  recognized,  partly  by  its  cylindrical  form,  partly  by  its  posi 
tion,  but  especially  by  the  fact  that  it  may  in  some  cases  be  detected 
changing  somewhat  from  day  to  day  in  form  and  direction,  as  the  intus- 
susception increases,  and  may  sometimes  also  be  felt  to  dilate  and  harden, 
and  then  subside,  under  the  influence  of  its  peristaltic  movements.  Fur- 
ther, in  those  cases  in  which  the  intussusception  extends  low  into  the 
rectum,  its  lower  extremity  may  be  detected  with  all  its  characteristic  fea- 
tures by  the  finger  inserted  into  the  anus. 

It  must  not  be  supposed,  from  the  foregoing  observations,  that  there 


42  DISEASES    OF   TIIE   INTESTINES    AND    PERITONEUM. 

is  always  a  wide  distinction  between  the  symptoms  of  invagination  of  the 
small  intestine  and  those  of  invagination  of  the  large  intestine.  There  is 
no  doubt  that  the  majority  of  jejunal  and  iliac  invaginations  are  marked 
by  the  violent  symptoms  and  rapid  progress  which  have  been  assigned  to 
them,  and  that  the  majority  of  invaginations  involving  the  large  intestine 
present  less  urgent  symptoms  and  assume  a  chronic  character.  But  un- 
doubtedly in  some  cases  invaginations  of  the  small  intestine  approximate 
in  symptoms  and  in  progress  to  those  of  the  large  intestine,  and  in  a  still 
larger  proportion  of  cases  caecal  and  colic  intussusceptions  are  attended 
from  an  early  period  with  symptoms  of  great  urgency  and  prove  rapidly 
fatal.  These  differences  depend  apparently  on  the  presence  or  absence 
of  strangulation,  which,  as  has  been  shown,  may  occur  in  connection  with 
any  form  of  invagination,  but  which  generally  occurs  early  when  the  small 
intestine  alone  is  aifected,  late  and  perhaps  not  at  all  when  the  large  in- 
testine is  the  seat  of  disease.  And  it  is  important  to  bear  in  mind  that  it 
is  this  very  strangulation,  leading  to  engorgement,  inflammation,  and  gan- 
grene of  the  invaginated  tract  of  bowel,  which,  while  it  gives  rise  to  the 
most  urgent  and  distressing  symptoms,  and  not  unfrequently  induces 
speedy  death,  is  effecting  the  separation  of  the  obstructing  mass,  and 
thus  leading  to  the  only  possible  solution  of  the  case  compatible  with 
restoration  to  health. 

There  are  several  additional  points  in  which  as  a  rule  differences  avail- 
able for  diagnosis  are  manifested  between  invaginations  of  the  small  and 
large  intestines  respectively.  Dr.  Brinton  has  especially  dwelt  upon  them. 
First,  tenesmus  is  common  in  invagination  of  the  large  intestine,  but  is 
not  necessarily  present,  and  is  generally  absent  when  the  small  intestine 
is  affected  ;  secondly,  haemorrhage  from  the  bowel  (connected  doubtless 
with  the  relative  degrees  of  congestion  of  the  invaginated  portion  of 
bowel)  is  much  more  copious  in  invagination  of  the  small  intestine  than 
in  that  of  the  large,  and  blood  may  also  in  the  former  case  be  vomited; 
thirdly,  obstruction  of  the  bowels  is  a  more  prominent  symptom  wlien  the 
small  intestine  is  affected  than  when  the  large  intestine  is  affected.  The 
remaining  points  on  which  Dr.  Brinton  insists,  namely,  the  situation  of 
the  tumor  within  the  abdomen,  and  the  discovery  of  the  end  of  the  intus- 
susception in  the  rectum,  have  been  already  discussed. 

Hitherto  it  has  been  supposed  that  the  case  of  intussusception  has 
been  uncomplicated  with  any  other  malady;  but  it  must  not  be  forgot- 
ten that  general  peritonitis  may  come  on  at  any  time  in  its  progress,  and 
that  it  is  sometimes  induced  by  perforation  of  the  bowel.  The  latter 
event  is  especially  apt  to  occur  at  the  time  of  separation  of  the  slough, 
and  necessarily  renders  a  case,  already  sufficiently  precarious,  hopeless. 

The  percentage  of  deaths  in  intussusception  must  be  very  large;  it  is 
very  difficult,  however,  if  not  impossible,  to  estimate  what  that  percen- 
tage is.  The  stage  at  which  patients  die,  and  the  immediate  cause  of 
death  present  very  great  varieties.  Dr.  Brinton  estimates  that  the  aver- 
age duration  of  cases  directly  fatal  is  five  and  a  half  days.  This  estimate 
may  probably  be  accepted  with  regard  to  those  cases  in  which  strangula- 
tion marks  the  onset  of  the  intussusception,  and  generally  therefore  with 
regard  to  invagination  of  the  small  intestine;  but,  as  ]3r.  Fagge  points 
out,  it  can  only  be  true,  in  a  qualified  sense,  of  invagination  of  the  largo 
intestine, — namely,  if  we  reckon  the  duration  of  the  case  from  the  first 
manifestation  of  symptoms  of  strangulation,  and  not  from  the  moment  at 
which  invagination  commenced,  which  may  have  been  many  weeks  pre- 
viously.    In  cases  in  which  there  is  not  immediate  strangulation,  the 


OBSTRUCTION   OF   THE    BOWELS.  43 

patient  may  survive  for  weeks  or  months,  ultimately  dying  of  exhaustion, 
or  killed  by  the  supervention  of  strangulation.  Even  after  the  slough 
has  been  discharged,  and  the  continuity  of  the  segment  of  bowel  above 
and  that  below  the  neck  of  the  invagination  has  been  established,  pernm- 
iient  recovery  would  seem  to  be  less  frequent  than  ultimate  death, — • 
death  being  induced  at  various  intervals  afterwards,  either  by  exhaustion 
or  by  the  effects  of  stricture  of  the  bowel.  Recovery  after  the  separa- 
tion of  a  portion  of  the  small  intestine  seems  to  be  more  frequent,  bot'a 
relatively  and  actually,  than  after  the  separation  of  a  portion  of  the  large 
intestine. 

(c)  The  Treatment  of  intussusception,  like  the  treatment  of  other 
forms  of  intestii.'al  obstruction,  must  be  on  the  whole  negative;  or,  to  be 
more  explicit,  the  less  actively  the  patient  is  treated,  the  more  likely  is 
he  to  have  his  life  prolonged,  and  ultimately  to  recover.  Here,  as  in 
most  other  kinds  of  obstructive  disease,  all  forms  of  purgatives  must  be 
eschewed,  everything  in  fact  must  be  avoided  which  can  have  the  effect  of 
promoting  peristalsis;  for  violent  movements  of  the  bowel,  independently 
of  any  other  mischief  they  may  effect,  naturally  tend  to  increase  the  sizo 
of  the  intussusception.  Neither  must  it  be  forgotten  that  the  special 
ground  on  which  alone  the  administration  of  purgatives  may  be  urged 
exists  less  in  intussusception  than  in  other  forms  of  obstructive  disease; 
for  constipation  is  rarely  complete  at  any  rate  for  more  than  a  few  days. 
On  the  other  hand,  opium  is  of  extreme  value  for  the  sake  both  of  reliev- 
ing the  pain  due  to  enteritis,  or  to  violent  peristalsis,  or  both,  and  of 
restraining  the  exaggerated  movements  of  the  bowel.  Dr.  Brinton  sug- 
gests that  belladonna,  on  account  of  its  relaxing  influence  on  the  un- 
stripped  muscular  fibres,  may  be  given  with  advantage,  either  alone  or 
combined  with  opium.  Enemata  are  often  beneficial,  partly  by  relieving 
the  lower  bowel,  partly,  perhaps,  by  acting  as  a  kind  of  internal  fomenta- 
tion. They  may,  however,  possibly  have  another  value,  at  all  events 
when  administered  in  large  quantities,  gradually  and  without  violence. 
Thus  there  is  some  reason  to  believe  that  where  the  large  intestine  is 
affected,  the  distention  caused  in  the  external  tube  of  the  intussusception, 
and  the  pressure  exerted  on  the  invaginated  portion  of  bowel  itself  by 
such  injections  cautiously  administered,  may  in  some  cases,  especially  those 
of  recent  origin,  and  where  the  length  of  bowel  involved  is  as  yet  small, 
avail  to  effect  its  restoration.  Inflation  of  the  bowel  2yer  anxim  was  long 
ago  recommended  for  the  same  purpose;  and  of  late  years  this  procedure 
has  been  revived,  and  several  cases  have  been  recorded  in  which  it  seems 
to  have  been  successful.  It  is  obvious,  however,  that,  as  is  the  case  with 
ordinary  enemata,  inflation  can  only  be  of  service  when  the  invagination 
involves  the  large  intestine,  and  when  it  is  in  an  early  stage.  But  in 
intussusception,  as  in  other  forms  of  disease  attended  with  obstruction, 
the  question  of  surgical  interference  is  not  unlikely  to  arise — Can  any  sur- 
gical operation  be  performed  with  a  prospect  of  benefit  ?  It  may  be  sup- 
posed that  it  would  be  no  difficult  matter,  after  opening  the  abdominal 
cavity,  to  withdraw  from  its  sheath  an  intussuscepted  portion  of  bowel; 
and  no  doubt,  if  adhesions  had  not  yet  been  formed,  or  if  gangrene  had 
not  yet  taken  place,  the  evolution  of  the  intussusception  might  Vje 
effected;  yet  even  then  considerable  force  would  have  to  be  applied, 
especially  if  the  intussusception  were  large,  and  much  risk  of  damage 
would  attend  the  process  of  retraction.  Assuming  then  that  an  opera- 
tion might  under  certain  conditions  be  attended  with  advantageous  re- 
sults, the  question  as  to  what  these  conditions  are  naturally  presents 


44  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

itself.  Now,  considering  how  acute  are  the  symptoms  which  attend 
invagination  of  the  small  intestine;  how  speedily  adhesions,  gangrene, 
and  separation  of  the  slough  begin  to  take  place  in  it;  how  difficult  it  is 
to  feel  sure  of  the  nature  of  the  case  at  that  early  period  when  alone  an 
operation  would  have  a  chance  of  success;  and  moreover  how  often  (com- 
paratively) the  patient  is  restored  to  health  by  the  spontaneous  discharge 
of  the  invaginated  length  of  bowel, — it  seems  scarcely  possible  to  avoid 
the  conclusion  that  in  these  cases  at  least  surgical  interference  should  be 
discarded.  But  when,  on  the  other  hand,  we  bear  in  mind  that  in  intus- 
susception of  the  large  intestine,  ultimate  recovery  is  exceptionally  rare, 
even  after  the  separation  of  the  invaginated  portion  of  bowel,  that  this 
separation  is  of  very  infrequent  occurrence,  and  that  the  invaginated 
bowel  is  apt  to  remain  in  a  fairly  healthy  condition  for  weeks,  sometimes, 
after  the  commencement  of  the  disease,  it  is  obvious  that  we  have  here  an 
opportunity  for  operation  and  a  chance  of  benefit  from  it  very  much  more 
favorable  than  those  which  iliac  and  jejunal  intussusceptions  offer.  And 
it  becomes  difficult  not  to  accept  the  conclusion  to  which  Dr.  H.  Fagge 
comes,  which  is  to  the  effect  that  it  is  in  these  cases,  and  in  these  alone, 
that  the  question  of  operating  should  be  seriously  entertained. 

Concluding  Remarks. — Before  finally  dismissing  the  subject  of  in- 
testinal obstructions,  it  may  be  convenient  to  consider,  however  briefly, 
some  of  the  more  important  points  upon  which  our  discrimination  of  such 
cases  of  obstruction  as  may  come  before  us  must  mainly  depend,  as  well  as 
some  of  those  points  of  treatment  which  have  a  general  value  in  reference 
to  them. 

(a)  Pain  is  a  more  or  less  general  and  prominent  symptom  in  all  cases 
of  obstruction,  but  it  varies  a  good  deal  in  different  persons,  both  in  dura- 
tion, character,  and  severity.  It  is  partly  the  pain  of  peritonitis,  partly 
that  of  colic,  and  these  may  be  present  separately,  or  variously  combined. 
Hence  it  can  be  readily  understood,  that  although  in  well-marked  cases 
the  character  of  the  pain  may  afford  us  valuable  assistance  in  determining 
whether  the  peritoneal  surface  is  alone  diseased,  or  whether  the  inflamma- 
tion affects  the  inner  tunics  only  of  the  bowels,  or  whether  it  involves 
pretty  equally  the  peritoneal,  muscular,  and  serous  coats;  in  others  it 
affords  no  evidence  whatever  of  a  trustworthy  kind.  I  have  a  distinct 
recollection  of  one  of  the  most  extensive  and  severe  cases  of  enteritis  I 
ever  saw,  associated  with  peritoneal  inflammation,  which  a  quite  well-ex- 
perienced medical  man  regarded  almost  to  the  last  as  one  of  simple  colic. 
It  may  be  added,  that  even  where  there  is  distinct  inflammation  of  a  length 
of  bowel,  the  pain  and  tenderness,  instead  of  occurring  immediately  su- 
perficial to  the  affected  gut,  are  frequently  most  marked  in  the  umbili- 
cal region.  This  latter  peculiarity  is  manifested  not  unfrequently  incases 
of  inguinal  or  femoral  hernia,  and  is,  indeed,  a  not  uncommon  characteris- 
tic of  affections  of  the  small  intestines. 

Painful  peristaltic  movements  coming  on  in  paroxysms  constitute  one 
of  the  most  distressing,  and  at  the  same  time  one  of  the  most  characteris- 
tic, symptoms  attendant  on  obstruction;  yet,  although  they  may  be  pres- 
ent in  a  marked  degree  in  all  forms  of  obstruction,  I  agree  very  much  with 
Dr.  Fagge  in  the  belief  that  they  are  for  the  most  part  most  severe  and 
most  constant  in  the  cases  of  longest  duration;  in  the  cases,  therefore,  in 
which  enteritis  is  either  not  present  at  all  or  occurs  late. 

{b)  Vomiting  is  rarely  if  ever  absent  from  the  various  affections  now 
under  consideration.  In  the  beginning  it  is  sympathetic  only,  and  in  that 
respect  resembles  the  vomiting  which  attends  many  other  affections  not 


OBSTRUCTION   OF   THE   BOWELS.  45 

necessarily  involving  the  gastro-intestinal  tract.  After  a  while,  however, 
in  most  if  not  all  cases,  it  owns  a  more  direct  cause.  The  bowels  above  the 
seat  of  obstruction  become  distended  with  contents,  partly  with  what  has 
I.een  taken  by  the  mouth  and  has  been  transmitted  onwards;  partly,  as  Dr. 
Brinton  justly  insists,  with  the  secretions  of  the  intestinal  walls;  those,  by 
the  combined  effects  of  simple  overflow,  of  the  peristaltic  movements  of 
the  bowels  and  of  the  pressure  exerted  on  the  bowels  from  without,  gain 
an  entrance  into  the  stomach,  and  then  become  vomited,  constituting 
what  is  called  stercoraceous  vomit.  The  storcoraceous  matter,  though 
never  in  cases  of  simple  obstruction  derived  from  the  large  intestine,  and 
probably  never  directly  from  the  lower  part  of  the  small  intestine,  still  ac- 
quires a  thin  pea-soup-like  aspect  and  a  faecal  odor,  which  the  normal  con- 
tents of  the  stomach  never  do  assume,  and  which  are  doubtless  the  result 
simply  of  the  long  residence  of  the  intestinal  contents  within  the  bowels, 
and  of  their  admixture  there  with  bile  and  other  secretions.  Vomiting  is 
generally  an  early  symptom  in  all  cases  of  intestinal  obstruction,  and  in 
those  of  acute  progress  may  continue  to  the  end  without  intermission. 
Yet  even  in  some  of  these  it  intermits,  and  may  be  absent  for  a  compara- 
tively long  period.  In  the  more  chronic  affections  its  occurrence  is  ex- 
tremely variable;  but  even  here  vomiting  generally  becomes  more  or  less 
constant,  and  then  stercoraceous  towards  the  close  of  life.  There  is  no 
doubt  that  vomiting  is  an  earlier,  a  less  interrupted,  and  a  more  severe 
symptom,  in  proportion  to  the  nearness  of  the  seat  of  obstruction  to  the 
stomach,  and  that  for  this  reason  it  is  a  more  marked  accompaniment  of 
obstruction  of  the  small  intestine  than  of  obstruction  of  the  large. 

(c)  Constipation  is  naturally  one  of  the  most  characteristic  phenom- 
ena of  obstructive  disease,  and  its  occurrence  is  of  high  diagnostic  value; 
yet  it  need  scarcely  be  repeated  that  faecal  matters  will  often  pass  with 
comparatively  little  difficulty  through  even  a  tight  stricture,  especially 
one  in  the  small  intestine;  nor  must  it  be  forgotten,  that  generally  at 
the  time  at  which  complete  obstruction  is  established,  the  bowel  below 
contains  a  larger  or  smaller  quantity  of  fasces,  which  may  be  removed 
naturally  or  by  injection,  and  the  removal  of  which  might  lead  to  the  be- 
lief that  no  obstruction  exists.  Scybala  may  sometimes  be  seen  in  the 
large  intestine,  after  death  from  complete  obstruction  of  the  ileum  of 
many  weeks'  standing.  Nevertheless,  constipation  of  an  insuperable 
character  is  for  the  most  part  an  exceedingly  pronounced  symptom;  com- 
ing on  suddenly,  and  persisting  in  cases  of  internal  strangulation,  and  of 
the  lodgment  of  gall-stones;  coming  on  somewhat  gradually,  or  at  all 
events  with  premonitory  stages,  in  most  cases  of  stricture  and  of  com- 
pression. In  intussusception  there  is  also  generally  sudden  constipation, 
of  various  duration,  but  the  invaginated  mass  (especially  when  the  large 
intestine  is  involved)  is  rarely  quite  impervious,  so  that  before  long  a 
slight  transmission  of  faecal  matter  begins,  at  all  events  in  all  chronic 
cases,  to  take  place;  moreover,  in  cases  of  intussusception,  blood  is  usually 
passed  by  stool  at  an  early  period,  and  more  or  less  continuously  through- 
out their  whole  duration.  The  discharge,  indeed,  from  the  large  intestine 
assumes  something  of  a  dysenteric  character,  and  becomes  associated  with 
symptoms  in  some  respects  resembling  those  of  dysentery.  In  intussus- 
ception of  the  small  intestine,  the  discharge  of  blood  is  sometimes  very 
copious. 

{(1)  Tirnior  and  Shape  of  Belly. — The  belly  in  cases  of  obstruction 
soon  becomes  more  or  less  tense  and  tympanitic  (unless,  indeed,  the  ob- 
struction be  in  the  upper  part  of  the  small  intestine)  in  consequence  oi 


46  DISEASES   OF   THE   INTESTINES    AND   PERITONEUM. 

the  distention  of  the  bowel  above  the  seat  of  stricture  by  accumulated 
faecal  matters  and  by  gas;  and  in  some  instances  the  shape  which  the 
abdomen  then  assumes  may  aid  in  the  diagnosis  of  the  site  of  obstruc- 
tion. Thus,  if  the  rectum  were  blocked  up,  distention,  though  soon 
extending  throughout  the  whole  of  the  large  intestine,  would  first  take 
place  and  be  most  extreme  in  the  sigmoid  flexure  and  descending 
colon,  in  the  situation  of  which  parts,  therefore,  some  special  fulness 
might  be  looked  for;  if  the  obstruction  existed  in  the  transverse  colon, 
some  fulness  would  not  improbably  be  discovered  in  the  right  flank,  and, 
according  to  circumstances,  in  the  position  of  a  larger  or  smaller  portion 
of  the  transverse  colon,  the  left  flank  presenting  a  comparative  absence  of 
fulness,  tension,  and  even  perhaps  of  weight;  while,  again,  if  the  impedi- 
ment occupied  the  lower  part  of  the  ileum,  the  distention  would  probably 
be  most  marked  in  the  mild  region  of  the  abdomen.  But,  as  has  been 
before  pointed  out,  the  evidence  afforded  by  the  general  shape,  and  resist- 
ance, and  weight  of  the  abdomen  must  be  received  with  great  caution, 
for  the  distended  bowels  very  readily  deviate  from  their  usual  position, 
and  diffuse  themselves,  as  it  were,  beneath  the  abdominal  surface,  displac- 
ing, or  at  least  concealing  the  bowels,  which  are  collapsed  and  empty. 
Sometimes,  indeed,  in  distention  of  the  large  intestine,  the  sigmoid  flexure 
extends  over  the  whole  front  of  the  abdomen,  and  with  the  aid  of  the 
other  lengths  of  colon  effectually  conceals  the  whole  of  the  small  intestine 
from  observation.  The  presence  of  an  abdominal  tumor,  as  distinguished 
from  mere  distention  of  bowel,  is  an  important  element  in  diagnosis.  It 
need  scarcely  be  said  that,  in  internal  strangulation,  and  in  most  cases  of 
compression,  no  tumor  is  likely  to  be  felt;  and  indeed  in  stricture  also, 
unless  the  stricture  depend  on  some  form  of  cancerous  growth,  or  be  asso- 
ciated with  the  presence  of  peritoneal  cancer,  or  be  in  the  rectum  within 
reach  of  the  finger,  no  tumor  will  probably  be  distinguished.  In  cases  of 
lodgment  of  gall-stones,  the  lump  produced  by  the  presence  of  the  gall- 
stone might,  one  should  suppose,  be  not  very  difficult  of  detection;  but 
unquestionably  in  the  great  majority  of  them,  of  those  even  under  the 
care  of  thoroughly  competent  practitioners,  no  tumor  has  been  recognized 
during  life.  Indeed  it  may  be  pretty  confidently  asserted  that  they  are 
rarely,  if  ever,  recognized.  This  fact  may  be  due  in  some  degree  to  the 
absence  generally  of  very  minute  manual  examination;  but  it  must  not 
be  forgotten  that  the  tumor  formed  by  a  gall-stone  is  really  not  very 
large,  that  the  swelling  of  the  bowel  above  the  obstruction  tends  to  cause 
the  point  of  obstruction  to  recede  from  the  surface,  or  to  mask  it,  and  that 
tenderness,  abdominal  fatness,  rigidity  of  muscles,  and  other  conditions, 
all  aid  more  or  less  to  interfere  with  successful  manual  examination.  Of 
all  the  different  forms  of  obstruction  which  have  been  enumerated,  intus- 
susception is  the  one  which  is  most  commonly  attended  with  the  presence 
of  manifest  tumor;  but  tumor  seems  to  be  far  more  common  in  connec- 
tion with  intussusceptions  involving  the  large  intestine  than  in  that  form 
of  the  disease  which  is  limited  to  the  ileum  and  jejunum.  It  is  needless 
to  repeat  the  characteristic  features  which  sucli  tumors  present. 

(e)  The  Condition  of  the  Urine  has  been  regarded  ever  since  Dr.  Bar- 
low's '  interesting  observations  on  the  subject  were  published,  as  some  in- 
dication either  of  the  seat  of  obstruction,  or  of  some  other  conditions 
connected  with  the  obstruction.  Dr.  Barlow  observed  that,  in  a  case  of 
his,  in  which  the  obstruction  was  in  the  duodenum,  there  was  an  almost 

'  Guy'a  Hospital  Reports,  vol.  ii.  Second  Series. 


OBSTRUCTION    OF   THE   BOWELS.  47 

total  suppression  of  urine;  and  there  is  no  doubt  that  in  many  cases  of 
obstruction  high  up,  the  same  phenomenon  is  manifested.  He  argued 
that  the  great  diminution  of  this  secretion,  in  his  and  in  similar  cases, 
was  caused  by  the  constant  vomiting  which  is  always  present  in  obstruc- 
tion of  the  upper  part  of  the  small  intestine,  and  by  the  little  available 
absorptive  surface  which  is  presented,  combining  to  prevent  the  entrance 
of  fluid  into  the  vascular  system,  and  the  supply  of  an  adequate  amount 
to  the  kidneys  for  the  maintenance  of  their  secretion.  And  he  argued 
further,  that  the  abundant  discharge  of  limpid  urine  which  is  frequently 
observed  in  cases  where  the  seat  of  obstruction  is  low  down,  is  to  be  ex- 
plained by  the  presence  of  entirely  opposite  conditions.  Further  obser- 
vation, however,  seems  to  show  that  although  there  may  be  a  tendency  on 
the  whole  to  a  diminished  secretion  of  urine  when  the  impediment  is  high 
up,  and  to  an  increased,  or  at  all  events  fairly  abundant  secretion  when 
the  impediment  is  low  down,  the  urine  is  in  many  cases  abundant  or 
scanty  apparently  quite  independently  of  the  seat  of  obstruction.  Dr. 
Brinton,  indeed,  suggests  that  the  diminished  secretion  of  urine  which  is 
frequently  met  with,  and  the  variability  of  which  phenomenon  he  fully 
recognizes,  is  rather  due  to  a  kind  of  vicarious  secretion  into  the  bowel 
above  the  seat  of  obstruction,  to  which  also,  rather  than  to  ingesta,  he 
no  doubt  rightly  attributes  most  of  the  distention  of  the  bowel  and  much 
of  the  vomit.  Mr.  W.  Sedgwick,'  however,  apparently  with  more  reason 
argues  that  the  diminution  or  suppression  of  the  urinary  secretion  is  re- 
lated to  the  suddenness  and  intensity  of  the  symptoms,  and  is  immedi- 
ately due  to  the  reflected  influence  of  the  abdominal  sympathetic  cen- 
tres. On  the  whole,  even  if  we  adopt  Mr.  Sedgwick's  views,  it  may  prob- 
ably be  accepted  as  generally  true  that  diminished  secretion  of  urine — 
often,  however,  temporary — attends  those  cases  in  which  the  symptoms 
are  of  sudden  occurrence  and  acute;  and  that  a  fairly  abundant  secretion 
of  this  fluid  characterizes  cases  which  are  chronic  in  their  course;  and 
that,  mainly  on  these  very  grounds,  suppression  or  diminution  of  urine  is 
far  more  common  in  cases  in  which  the  small  intestine  is  obstructed,  than 
in  those  in  which  the  impediment  occupies  the  larger  bowel. 

{/)  The  Mode  of  Invasion  is  often  of  great  value  in  reference  to 
diagnosis.  Internal  strangulation  and  intussusception  always  begin  sud- 
denly, with  more  or  less  acute  and  severe  symptoms.  Obstruction  by 
gall-stones  might  be  expected  to  be  preceded  by  symptoms  indicative  of 
the  passage  of  a  gall-stone  from  the  bladder  into  the  duodenum,  and  by 
further  symptoms  arising  in  the  course  of  its  journey  to  the  spot  at  which 
it  becomes  finally  arrested;  and  sometimes,  but  by  no  means  always,  the 
history  of  such  premonitory  symptoms  can  be  pretty  clearly  obtained. 
Stricture,  on  the  other  hand,  and  in  a  less  marked  degree  obstruction 
from  compression  of  the  bowel,  are  in  the  great  majority  of  cases  preceded 
for  a  more  or  less  considerable  length  of  time  by  symptoms  which  point 
to  what  is  going  on,  and  which  for  the  most  part  have  a  resemblance  to 
those  which  attend  the  fatal  attack. 

(//)  The  Duration  of  Life  after  the  commencement  of  symptoms 
which  lead  to  belief  in  the  presence  of  one  of  the  maladies  under  consid- 
eration varies  considerably  in  different  cases.  The  continuance  of  life  is 
compatible  with  the  persistence  of  mere,  though  complete,  colic  or  rectal 
obstruction  of  several  weeks'  or  even  months'  duration.  But  death  as  a 
rule  supervenes  much  earlier  in  proportion  as  the  impediment  is  situated 

'  Med.-Chir.  Trans.,  vol.  IL 


48  DISEASES    OP   TIIE   INTESTINES   AND    PERITONEUM. 

nearer  to  the  stomach.  When,  however,  enteritis  is  associated  with  ob- 
struction, then,  wherever  the  obstruction  may  be,  the  progress  of  the  case 
is  always  very  rapid,  and,  dating  from  the  commencement  of  the  enteritic 
symptoms,  rarely  occupies  more  than  a  week,  often  only  three  or  four 
davs.  Hence  internal  strangulations,  obstructions  by  gall-stones,  and 
intussusceptions  in  which  strangulation  occurs  (more  particularly  there- 
fore intussusceptions  of  the  small  intestine),  are  usually  fatal  witliin  a 
few  davs  after  the  commencement  of  symptoms;  while  obstructions  from 
stricture  or  compression,  and  generally  also  those  from  intussusception 
affecting  the  larger  bowel,  for  the  most  part  present  a  comparatively 
chronic  progress. 

(h)  /Statistics. — There  are  certain  striking  facts  deducible  from  the 
statistics  of  obstructive  diseases,  which  it  is  always  well  to  bear  in  mind. 
First,  as  regards  age  and  sex.  It  is  a  well-ascertained  fact  that  obstruc- 
tion by  gall-stones  always  occurs  late  in  life,  generally  over  fifty,  and 
about  four  times  as  frequently  in  women  as  in  men;  it  appears  also  that 
intussusception  maj'  occur  at  all  ages,  and  is  at  all  ages  somewhere  about 
twice  as  common  in  males  as  in  females,  but  that  of  intussusceptions  in- 
volving the  large  intestine  (wliich  form  pretty  nearly  two-thirds  of  the 
total  number  of  fatal  intussusceptions),  probably  fully  one-half  occur  in 
children  under  seven  years  of  age;  it  appears  further  that  stricture  (if  we 
omit  strictures  due  to  congenital  malformation)  is  a  disease  of  adult  life 
and  occurs  indifferently  in  both  sexes.  Next,  in  reference  to  the  portion 
of  intestine  involved.  Stricture,  as  a  cause  of  death,  belongs  almost  with- 
out exception  to  the  large  intestine,  and  not  only  so,  but  at  least  three- 
fourths  of  the  total  number  of  strictures  are  situated  below  the  middle  of 
the  transverse  colon;  compression  and  traction  belong  essentially  to  the 
small  intestine,  and  may  be  regarded,  as  ])r.  Fagge  observes,  in  a  practi- 
cal point  of  view  as  the  strictures  of  that  tract;  internal  strangulation 
occurs  more  particularly  in  connection  with  the  small  intestine,  or  with 
the  caecum  and  sigmoid  flexure;  gall-stones,  with  hardly  an  exception, 
become  arrested  somewhere  in  the  jejunum  or  ileum;  and  the  large  intes- 
tine is  involved  in  intussusception  at  least  twice  as  often  as  the  small 
intestine  alone.  Lastly,  with  respect  to  the  relative  frequency  of  the 
several  lesions,  it  may  be  well  to  quote  Dr.  Brinton's  figures,  based  on 
600  deaths  from  obstruction;  according  to  which  it  appears  that  out  of 
100  cases,  43  are  cases  of  intussusception,  17  are  cases  of  stricture,  4'8 
are  cases  of  impaction  of  gall-stones,  27*2  are  cases  of  internal  strangula- 
tion (including,  however,  all  those  cases  which  have  been  here  described 
as  compressions),  and  8  are  cases  of  torsion,  in  regard  to  which  the  opin- 
ion has  been  previously  expressed  that  they  are  simply  cases  of  uncom- 
plicated enteritis. 

(^)  Finally  in  respect  of  Treatment,  there  are  a  few  established  prin- 
ciples which  must  gviide  us  in  all  cases  of  sudden  obstruction  of  the 
bowels,  and  especially  in  all  cases  where  that  sudden  obstruction  is  at- 
tended with  symptoms  of  enteritis.  First,  purgatives  however  mild  can 
do  no  good,  may  do  immense  harm,  and  must  be  altogether  discarded. 
Secondly,  opiates  and  other  sedatives  must  be  administered  largely,  or  at 
least  sufficiently  largely  to  produce  some  visible  effect  in  relieving  pain 
and  giving  rest,  and  should  in  most  cases  be  administered  by  subcuta- 
neous injection.  Thirdly,  but  little  food  and  stimulus  should  be  adminis- 
tered by  the  mouth,  for  they  are  almost  always  immediately  rejected,  or 
if  retained  fail  to  be  absorbed,  and  then  add  only  to  the  bulk  of  fiecal 
matters  distending  the  bowel  above  the  seat  of  obstruction,  in  either  case 


OBSTB'JCTION    OF   THE    BOWELS.  40 

adding  to  the  patient's  distress  and  tending  to  hasten  death.  Food  given 
by  the  mouth  should  be  in  small  quantities,  fluid,  and  easy  of  absorption 
and  digestion.  There  is  no  reason,  however,  in  many  cases,  vi'hy  we 
should  not  endeavor  to  support  the  patient's  strength  by  nutritious  ene- 
mata.  Fourthly,  operations  for  the  relief  of  intestinal  obstructions  are 
rarely  followed  by  satisfactory  results;  nevertheless,  if  there  seem  a 
chance,  however  remote,  of  lengthening  the  life  of  a  patient  who  is  other- 
wise doomed  to  speedy  death,  few  would  hesitate  to  catch  at  that  chance. 
In  some  forms  of  obstruction  an  operation  must  from  the  very  nature  of 
things  be  at  least  useless,  as  for  example  in  simple  enteritis,  in  torsion,  in 
most  cases  of  compression  of  the  bowel,  and  in  the  impaction  of  gall- 
stones; but  there  can  be  no  doubt  that  if  an  operation  were  performed  at 
an  early  date,  internal  strangulations  might  be  relieved  with  fair  success, 
and  intussusceptions  might  be  retracted  with  frequent  benefit.  Dr.  Fagge 
is  doubtless  judicious  in  recommending  an  operation  for  the  retraction  of 
ileo-cfecal  intussusception,  for  reasons  which  have  been  given  previously  ^ 
and  there  can  be  no  doubt  that  if  the  evidence  points  at  all  strongly  to 
internal  strangulation,  an  early  resort  to  surgery  should  be  had.  It  need 
scarcely  be  insisted  on  that  no  patient  suffering  from  sudden  obstruction 
with  enteritic  symptoms,  in  whom  an  external  hernia,  whether  strangu- 
lated or  not,  exists  or  has  existed,  should  be  allowed  to  die  without 
undergoing  an  exploratory  operation  at  the  seat  of  hernia. 
4 


ULCERATION  OF  THE  BOWELS. 

By  Johx  Syeb  Bkistowe,  M.D.,  F.R.C.P. 


XJlceration  of  the  bowels,  using  the  word  in  its  widest  sense  to  indi- 
cate all  those  cases  in  which  the  mucous  membrane  is  partially — no  matter 
how  or  why — destroyed,  is  a  lesion  of  very  common  occurrence,  sometimes 
induced  by  the  extension  of  disease  from  the  exterior  of  the  intestine, 
more  commonly  the  result  of  morbid  processes  commencing  in  its  mucous 
and  sub-mucous  tissues. 

I.  Pathology. — (a)  Ulceration  beginning  from  within. — Ulceration 
which  originates  in  connection  with  the  mucous  membrane  may  be  found 
at  any  part  of  the  intestinal  tract;  but  there  are  certain  situations  in 
which  it  is  met  with  much  more  frequently  than  elsewhere:  these  are  the 
duodenum,  the  ileum  (especially  towards  its  outlet),  the  cascum,  ascending 
colon,  sigmoid  flexure  and  rectum;  in  other  words,  the  commencement 
and  the  termination  of  both  the  larger  and  the  smaller  bowel. 

The  causes  of  ulceration  are  very  various,  and  are  not  always  easy  to 
define,  and  still  less  easy  in  practice  to  recognize.  Some  forms  of  it  are 
no  doubt  distinctly  the  result  of  the  liquefaction  or  destruction  of  some 
specific  deposit,  as  in  enteric  fever  and  in  tuberculosis,  and  perhaps,  in  the 
latter  stages  of  syphilis;  and  some,  as  possibly  the  dysenteric,  are  due  to 
some  specific  kind  of  inflammation.  But  in  a  considerable  number  of 
cases  the  causes  of  ulceration  are  local;  the  bowel  is  wounded  by  some 
sharp  body  which  has  been  swallowed,  or  is  rubbed  and  irritated  by  some 
partially  arrested  solid  mass,  or  is  fretted  by  the  constant  passage  over  it 
of  acrid  fluids,  or  presents  some  localized  point  or  points  of  inflammation, 
which  own  no  more  manifest  cause  than  does  a  pustule  of  impetigo,  a 
bleb  of  pemphigus,  or  an  ordinary  boil.  It  may,  however,  be  conceded, 
that  even  in  these  latter  cases  the  general  condition  of  the  patient  has 
often  much  to  do,  at  all  events  indirectly,  with  the  production  of  the 
ulceration:  that,  for  example,  on  the  one  hand  the  fluids  which  irritate 
are  often  irritating  in  consequence  of  being  unhealthy;  and,  on  the  other 
hand,  the  fretted  bowel  often  inflames  or  ulcerates  under  their  influence, 
because  it  was  previously  congested,  or  its  circulation  was  sluggish. 

Many  forms  of  inflammation  of  the  skin  are  attended  with  an  excessive 
production  of  epidermis,  or  with  the  exudation  of  matter  into  or  beneath 
the  epidermis,  and  thus  become  characterized  by  the  development  of 
squamas  or  of  crusts,  on  the  removal  of  which  a  more  or  less  raw  surface 
is  left,  and  beneath  which  ulceration  is  apt  to  take  place.  The  varieties 
of  cutaneous  inflammation,  here  very  briefly  indicated,  are  for  the  most 
part  easy  of  separate  recognition,  yet  they  not  infrequently  merge  one 
into  the  other.  But  on  mucous  surfaces  the  distinctions  between  scaly, 
vesicular,  and  even  pustular  affections  are  rarely,  if  ever,  very  obvious,  the 


52  DISEASES    OF    THE   INTESTINES    AND    PERITONEUM. 

delicacy  and  moisture  of  the  epithelium  interfering  alike  with  the  forma- 
tion of  a  mere  dry  scale  and  with  the  limited  accumulation  of  fluid  be- 
neath it.  I  have  used  the  term  "  croupous  "  on  another  page,  to  indicate 
those  forms  of  intestinal  inflammation  in  which  the  mucous  membrane  is 
found  covered  with  an  opaque  adherent  film,  composed  of  corpuscular 
elements,  derived  partly  from  its  surface,  partly  from  its  glandular  invo- 
lutions: but  I  have  used  it  in  no  specific  sense,  and  believe  that,  in  many 
cases  at  least,  the  film,  or  false  membrane,  is  homologous  with  the  scurf 
of  pityriasis,  the  scales  of  lepra,  or  the  vesicles  of  eczema.  Ulceration  of 
the  bowels  not  infrequently  commences  with  "  croupous  "inflammation:  a 
linear  or  irregularly  polygonal  or  stellate  patch  of  more  or  less  intense 
congestion  and  tumefaction  makes  its  appearance,  which  soon  becomes 
covered  (excepting,  perhaps,  at  the  edges  by  which  it  may  be  extending) 
with  an  opaque  whitish  or  buff-colored  exudation,  which  is  somewhat 
friable  and  granular  on  the  surface,  and  extends  by  rootlets  into  the  Lie- 
berkiihnian  follicles;  the  patch  of  exudation  after  a  time  separates,  and 
leaves  sometimes  a  sound  surface,  sometimes  a  slight  excoriation,  or  even 
a  distinct  ulcer,  manifested  by  a  somewhat  cupped  grayish  or  yellowish 
surface  and  a  well-marked  margin  of  congested  raucous  membrane.  Ul- 
cers commencing  thus  may  be  met  with  in  any  part  of  the  bowels,  but 
are  much  more  common  in  the  large  intestine  than  elsewhere.  In  the 
small  intestine  they  chiefly  afl;ect  the  free  edges  of  the  valvulae  conni- 
ventes,  and  in  the  large  intestine  either  the  projecting  ridges  formed  by 
the  intervals  between  the  sacculi,  or  those  which  correspond  to  the  longi- 
tudinal muscular  bands.  They  are  very  apt  to  occur,  particularly  in  the 
large  intestine,  in  the  course  of  pneumonia,  and  in  cases  in  which  the 
patient  is  dying  from  many  forms  of  chronic  disease,  such  as  Bright's  dis- 
ease of  the  kidneys,  cirrhosis,  cancer,  chronic  phthisis;  and,  from  the 
peculiar  position  which  they  occupy,  there  is  reason  to  believe  that  they 
depend,  partly  at  least,  on  irritation  by  the  intestinal  contents.  Occa- 
sionally we  find  large  tracts  of  bowel  more  or  less  deeply  congested,  and 
studded  with  irregular  patches  or  bands,  or  an  imperfect  network,  consist- 
ing partly  of  croupous  exudation,  partly  of  consecutive  ulceration. 

In  other  cases  ulceration  commences  either  from  distinct  mechanical 
injury  or  from  more  gradual  erosion;  the  ulcer  then  being  roundish,  or 
more  or  less  irregular  in  form,  varies  in  size,  presenting  a  more  or  less 
congested  and  well-defined,  but  not  necessarily  thickened,  margin,  and  a 
more  or  less  irregularly  excavated  shreddy  grayish  surface.  Such  ulcers 
may  be  observed  when  gall-stones  or  other  solid  bodies  have  lain  for  some 
time  in  contact  with  a  portion  of  intestinal  surface;  they  occur  also  in  the 
large  intestine,  when  it  has  been  long  distended  with  accumulated  faecal 
contents.  In  several  cases  of  long-continued  constipation,  I  have  seen 
the  mucous  surface  of  the  larger  bowel  studded  with  tracts  varying  from 
about  one  to  twelve  square  inches  in  area,  consisting  of  groups  of  circular 
ulcers  of  the  kind  now  under  consideration  from  half  an  inch  downwards 
in  diameter,  and  separated  from  one  another  by  a  network  formed  of  con- 
gested and  partly  undermined  bands  of  mucous  membrane. 

Sometimes,  again,  ulcers  obviously  originate  in  patches  of  sub-mucous 
suppuration,  as  we  see  occasionally  in  pyaemia,  or  in  patches  of  sub-mu- 
cous slough,  like  an  ordinary  furuncle.  Among  these  may,  perhaps,  be 
reckoned  the  ulcerative  inflammation  of  the  follicles  of  the  colon,  which 
Kokitansky  describes,  and  which  seems  by  many  to  be  considered  the 
earliest  stage  of  dysentery.  The  follicles  first  enlarge  to  between  the  size 
of  a  tare  and  a  pea,  and  become  surrounded  by  a  dark  red  halo  of  conges- 


ULCERATION    OF    THE   BOWELS.  53 

tion,  and  then,  undergoing  suppuration,  discharge  their  contents  into  tho 
bowel  by  an  ulcerated  opening,  which  eventually  enlarges,  and  forms  a 
circular  ulcer  with  overlapping  edges.  When  the  follicles  are  widely 
affected,  the  mucous  membrane  presents  in  the  first  instance  a  generally 
congested  tuberculated  surface,  upon  which,  after  a  short  time,  groups  of 
small  tolerably  deep  circular  ulcers  make  their  appearance. 

In  other  cases,  again,  ulceration  is  produced  by  the  separation  of  a 
slough.  In  various  parts  of  the  small  intestine,  but  perhaps  most  com- 
monly in  the  duodenum  and  jejunvim  as  well  also  as  in  the  oesophagus  and 
stomach,  circumscribed  patches  of  intense  congestion  or  of  extravasation 
of  blood  appear  in  the  substance  of  the  mucous  membrane,  the  patches 
shortly  dying,  and  coming  away  either  bit  by  bit  or  in  mass.  The  forma- 
tion and  separation  of  such  patches  are  often  effected  with  little  obvious 
change  in  the  parts  immediately  surrounding  them;  there  is  often  no  un- 
wonted congestion  observable,  and  the  pits  which  are  formed  by  their 
removal  for  the  most  part  speedily  become  effaced.  I  believe  they  are 
most  commonly  seen  in  cases  of  small-pox,  typhus,  and  other  such  dis- 
eases. A  somewhat  similar  condition  is  sometimes  observed  in  the  val- 
vulre  conniventes,  and  still  more  frequently  in  the  transverse  projections 
from  the  interior  of  the  larger  intestine,  the  free  edges  of  which  then  pre- 
sent a  line  of  ulceration,  which  looks  as  though  it  had  been  formed  by  a 
mere  splitting  of  the  diseased  mucous  membrane,  and  presents  either  an 
ashy  or  a  yellow  flocculent  surface. 

But  sloughing  to  a  much  more  serious  extent  is  sometimes  met  with, 
especially  in  the  large  intestine;  patches  of  surface  become  livid,  or  brown, 
or  nearly  black  with  congestion,  and  then  their  central  region  assumes  a 
gray  or  ashy  color,  gets  shrunken,  depressed,  and  softened,  and  soon  breaks 
down  into  a  soft  shreddy  substance,  which  partly  becomes  detached  and 
partly  adheres  to  the  floor  of  the  excavation,  and  to  the  not  yet  broken- 
down  edges,  which  latter  tend  to  spread,  and  to  involve  more  and  more  of 
the  surrounding  tissues.  Occasionally  extensive  tracts  of  the  mucous  sur- 
face of  the  large  intestine  are  covered  with  sloughing  patches,  originating 
in  the  manner  just  described. 

It  is  not  pretended  that  all  non-specific  ulcers  arise  in  one  or  other  of 
the  modes  here  enumerated,  or  that  the  several  varieties  enumerated  are 
even  in  the  beginning  in  all  cases  essentially  distinct  from  one  another. 
Still  less  do  they  necessarily  maintain  these  distinctions  in  the  later  stages 
of  their  progress.  Fully  formed  ulcers  indeed  present  a  considerable  vari- 
ety of  appearance,  dependent  mainly  on  the  processes  which  are  taking 
place  in  them.  Thus,  when  they  are  in  process  of  healing,  we  find  the 
general  surface  smooth  and  clean,  or  it  may  be  granulating,  the  edges 
little  if  at  all  thickened  or  congested,  perhaps  puckered,  and  sloping  more 
or  less  obviously  to  the  surface  of  the  ulcer  with  which  they  are  continu- 
ous; when  they  are  sluggish,  the  edges  are  more  or  less  tumid  and 
rounded,  and  it  may  be  overhanging,  and  the  general  surface  smooth,  or 
somewhat  irregular  and  flocculent;  and  again,  when  they  are  spreading, 
the  surrounding  mucous  membrane  presents  more  or  less  intense  congestion 
and  swelling,  and  the  immediate  edge  of  the  ulcer  is  either  flocculent  and 
ash-colored,  or  presents  a  vivid  red,  raw,  bleeding  wall,  or  forms  a  more  or 
less  complete  rim  of  distinct  gangrene.  The  floor  of  an  intestinal  ulcer  is 
generally  constituted  by  the  sub-mucous  tissue,  but  not  infrequently  the 
transverse  muscular  fibres  are  distinctly  exposed,  especially  in  an  ulcer 
which  is  still  spreading;  and  when  the  ulcer  tends  to  perforate  the  bowel 
the  muscular  coat  itself  becomes  opaque,  eroded,  and  in  parts  destroyed. 


54  DISEASES    OF   THE   INTESTIXES    AND    PERITONEUM. 

The  account  just  given  applies  to  individual  ulcers.  But  very  fre- 
quently, and  much  more  frequently  in  the  large  than  in  the  small  intestine, 
numerous  ulcers  are  present  at  the  same  time,  and  tend  to  increase  either 
in  number  or  size  and  to  coalesce  in  a  greater  or  less  degree;  and  then, 
according  to  the  stage  to  which  the  ulceration  has  advanced,  we  meet  in 
different  cases  with  either  a  number  of  roundish  ulcers  separated  by  an 
imperfect  network  of  mucous  membrane,  or  interlacing  networks  of  ulcer- 
ation and  of  mucous  membrane,  or  islets  of  mucous  membrane  in  an 
expanse  of  ulceration;  or  lastly,  extensive  tracts  from  which  the  mucous 
coat  has  been  wholly  removed.  In  these  cases  the  transverse  muscular 
fibres  are  often  freely  exposed,  and  the  remains  of  mucous  membrane  are 
red  and  swollen  and  rounded,  and  form  tubercular  excrescences.  The 
bowel,  moreover,  is  frequently  much  contracted. 

Some  of  the  specific  forms  of  intestinal  ulceration  have  been  elsewhere 
considered.  There  is  only  one,  indeed,  tubercular  ulceration  which  needs 
anything  like  minute  description  here.  Still  it  may  be  convenient  briefly 
to  advert  to  some  of  the  more  important  features  which  do,  or  are  sup- 
posed to,  distinguish  them  severally.  I  am  not  aware  that  syphilitic 
ulceration  has  been  surely  recognized  in  the  alimentary  canal,  except  in 
the  neighborhood  of  its  inlet  and  outlet;  intestinal  ulceration,  however, 
is  often  met  with  in  persons  who  have  died  when  under  the  influence  of 
the  syphilitic  virus,  and  it  seems  at  least  reasonable  to  suppose  that  in 
some  of  these  cases  the  ulceration,  even  though  it  presents  no  visible  dis- 
tinctive mark,  owns  a  syphilitic  origin.  Dysenteric  ulceration  occupies 
the  large  intestine,  and  occasionally  invades  also  the  lower  part  of  tho 
ileum.  The  mode  of  origin  of  the  tropical  form  of  the  disease  is  variously 
described  by  many,  including  the  late  Dr.  Baly,  it  is  considered  to  arise 
ill  inflammation  and  suppuration  of  the  solitary  glands;  by  others  it  is 
believed  to  originate  in  a  croupous  form  of  inflammation;  and  no  doubt 
it  sometimes  commences  with  intense  general  inflammation,  passing  at 
once  into  gangrene.  But,  however  it  may  begin,  it  tends  to  the  rapid 
destruction  of  extensive  tracts  of  mucous  membrane,  and  to  that  chronic 
condition  of  more  or  less  extensive  rawness  which  has  been  above  referred 
to.  In  typhoid  fever  a  deposit  takes  place  in  the  solitary  glands,  and  in 
Peyer's  patches  (more  frequently  in  the  latter  than  in  the  former),  which 
become  congested,  softened,  and  form  flat  wheal-like  elevations.  At  the  end 
of  a  few  days,  it  may  be  a  week,  the  bulk  of  the  enlarged  gland  begins 
to  slough,  a  line  of  ulceration  forms  around  the  slough,  and  this  latter 
acquires  a  peculiar  yellow  or  brownish  hue.  In  a  short  time  the  slough 
separates,  leaving  a  circular  or  sinuous  ulcer  with  congested  tumid  edges, 
and  an  excavated  surface,  limited  either  by  the  sub-mucous  tissue  or  by 
the  transverse  muscular  fibres.  Then  usually  the  edges  begin  to  resume 
the  normal  thickness  and  color  of  mucous  membrane,  and  to  blend  gradu- 
ally with  the  contiguous  surface  of  the  ulcer,  which  itself  fills  up  and  con- 
tracts, and  ultimately  heals  with  a  scarcely  or  not  at  all  visible  cicatrix. 
At  other  times  the  ulcer  remains  irritable  or  sluggish,  or  spreads  both  iji 
surface  and  depth,  either  by  gradual  erosion,  or  by  sloughing,  or  by  the 
phagedainic  process.  And  then  sometimes  haemorrhage,  sometimes  per- 
foration of  the  bowel  takes  place.  Typhoid  ulcers  vary  in  size  from  about 
that  of  a  split  pea  to  that  of  the  largest  of  Peyer's  patches.  They  are 
always  most  marked  immediately  above  the  ileo-caecal  valve  (to  which 
part  they  are  sometimes  limited),  and  extend  thence,  gradually  decreasing 
jn  number  and  size,  upwards  through  the  ileum  and  occasionally  the  jeju- 
num.    They  occur  in  the  large  intestine  in  about  half  the  total  number  of 


ULCERATION    OF   THE   BOWELS.  55 

cases,  being  then  of  smaller  size  than  those  in  the  ileum,  and  diminishing 
in  number  from  the  caecum  downwards. 

Tubercular  disease  of  the  mucous  membrane  of  the  bowel  is  one  of  the 
most  frequent  forms  in  which  the  tubercular  diathesis  reveals  itself,  and 
certainly  the  most  frequent  cause  of  intestinal  ulceration.  It  occurs  in 
rather  more  than  one  half  of  the  total  number  of  cases  of  pulmonary  con- 
sumption, and  rarely  if  ever  independently  of  it;  and  it  is  often  associated 
with  peritoneal  and  other  varieties  of  abdominal  tubercle.  It  affects  pri- 
marily the  same  structures  as  areaifected  in  enteric  fever,  namely,  Peyer's 
patches  and  the  solitary  glands;  and  in  the  small  intestine  therefore  is 
always  most  advanced  and  most  abundant  immediately  above  the  ileo- 
caecal  valve,  from  whence  upwards  (although  it  may  extend  throughout 
the  ileum  and  jejunum)  it  gradually  diminishes.  It  affects  the  ciecum 
more  than  any  other  part  of  the  large  intestine,  involving  also  the  ileo- 
cecal valve  and  the  vermiform  appendage;  but  it  may  form  patches 
throughout  the  whole  of  the  colon.  The  large  intestine  and  small  intes- 
tine are  affected  by  it  with  equal  frequency',  and  they  are  both  affected  in 
combination  about  twice  as  frequently  as  they  are  each  affected  separately. 
The  tubercular  material  is  deposited,  either  in  the  form  of  gray  granules 
or  of  yellow  cheesy  masses,  in  the  substance  of  the  congested  and  swollen 
glands,  and  generally  soon  undergoes  softening,  producing  a  small  pretty 
deep  ulcer  with  thickened  elevated  overhanging  edges.  When  several  of 
these  deposits  have  softened  side  by  side,  as  happens  in  Peyer's  patches, 
the  ulcerated  area  presents  in  the  first  instance  a  kind  of  honeycombed 
appearance,  the  small  ulcers  being  separated  by  more  or  less  complete 
bridles  of  yet  undestroyed  and  thickened  mucous  membrane,  and  the 
general  margin,  which  is  also  thickened,  presents  a  sinuous  or  scolloped 
outline.  Tubercular  ulcers  generally  tend  to  spread  by  the  successive 
deposition  and  softening  of  tubercles  at  their  edges,  the  tubercles  not 
being  then  necessarily  limited  to  the  glands;  and  by  this  process  they 
often  extend  over  a  considerable  area.  In  the  large  intestine  the  whole 
mucous  membrane  of  the  caecum  is  sometimes  thus  destroyed,  and  often 
very  extensive  tracts  of  ulceration  are  found  to  stud  the  surface  of  the 
colon  at  more  or  less  distant  intervals.  In  the  small  intestine  tubercular 
ulceration  has  a  remarkable  tendency  to  spread  in  the  transverse  direction 
and  frequently  forms  bands  from  half  an  inch  to  an  inch  or  more  wide, 
occupying  the  whole  circumference  of  the  bowel.  Many  of  these  are 
sometimes  met  with  at  short  distances  from  one  another  throughout  the 
greater  part  of  the  small  intestine.  In  most  cases  the  ulcers  still  go  on 
enlarging  up  to  the  patient's  death,  and  occasionally  they  lead  to  haemor- 
rhage or  to  perforation.  Sometimes,  however,  they  cicatrize  more  or  less 
perfectly:  some  cicatrizing  indeed  while  others  are  spreading  or  new  ones 
are  forming.  But,  owing  to  the  extensive  destruction  wliich  tubercular  ul- 
ceration occasions,  cicatrization  is  generally  attended  with  considerable  con- 
traction; so  that  sometimes  in  the  small  intestine,  in  the  cecum,  or  in  the 
colon,  the  calibre  of  the  bowel  becomes  in  consequence  so  much  diminished 
as  to  produce  a  real  stricture.  Sometimes,  again,  tubercular  deposits  dr}' 
up  or  become  absorbed  without  ever  undergoing  actual  ulceration;  and  it 
is  not  a  rare  thing  to  find,  in  cases  of  chronic  phthisis,  both  in  the  large 
and  small  intestines,  small,  irregular  elevated  patches,  sometimes  associated 
with  ulceration  or  the  remains  of  ulceration,  which  present  a  dark  grayish 
hue  and  a  cicatrix-like  appearance,  the  surface  being  studded  with  small 
granules,  the  edges  being  puckered  and  prolonged  by  irregular  bands  into 
the  membrane  around,  an   appearance  having  some  resemblance  to   that 


56  DISEASES    or   THE   ITTTESTINES    AND    PERITONEUM. 

produced  by  superficial  lupus.  The  peritoneal  surface  corresponding  to 
tubercular  ulcers  of  the  mucous  membrane  is  generally  studded  with  mi- 
nute gray  granulations  and  the  lymphatics  ramifying  in  the  walls  of  the 
same  part,  and  those  extending  between  it  and  the  nearest  mesenterio 
glands  are  often  filled  with  opaque  white  creamy  or  cheesy  contents.  It 
may  be  added  that  extensive  chronic  ulceration  of  the  large  intestine, 
which  has  all  the  characters  previously  described  as  belonging  to  the  later 
stages  of  dysentery,  or  of  non-specific  forms  of  intestinal  ulceration,  is 
often  met  with'  in  phthisical  patients;  in  whom  there  is  no  tubercle  in  any 
part  of  the  bowel  except  the  ileum,  and  where  therefore  it  may  be  a 
question  whether  the  ulceration  originated  directly  in  the  breaking  down 
of  tubercle,  or  whether,  as  seems  most  likely,  it  took  its  origin  in  simple 
excoriation  caused  by  the  constant  passage  of  irritating  secretions  from 
the  tubercular  bowel  above,  just  as  the  mucous  membrane  of  the  trachea 
becomes  so  often  excoriated  in  the  course  of  pulmonary  phthisis. 

Many  intestinal  ulcers  doubtless  cicatrize  and  leave  behind  them  no 
traces  of  their  former  existence,  or,  at  most,  a  smooth  depression  with 
puckered  edges.  In  other  cases,  however,  and  indeed  in  a  large  propor- 
tion of  them,  results  of  more  or  less  serious  importance  follow. 

Sometimes,  where  a  vast  continuous  extent  of  surface  has  been  de- 
stroyed, as  we  see  occasionally  in  the  rectum  and  other  parts  of  the 
large  intestine,  the  mucous  membrane  never  does  become  restored;  and 
even  in  cases  where  the  destruction  of  tissue  has  been  much  more  limited, 
the  ulcer  may  assume  the  character  often  presented  by  the  chronic  ulcer 
of  the  stomach,  and  be  ready,  as  that  is,  to  break  out  again  and  again 
under  apparently  the  most  trivial  provocation.  But  generally  whon  a 
large  ulcer  heals  wholly  or  in  part,  some  degree  of  contraction  of  the 
calibre  of  the  bowel  is  the  consequence, — contraction  which  takes  jilace 
both  in  length  and  in  breadth,  but  which  from  obvious  causes  manifests 
itself  most  conspicuously  in  the  latter  direction.  Stricture,  in  fact,  often 
follows  such  contraction,  but  especially,  and  indeed  almost  exclusively, 
when  the  ulceration  which  has  given  rise  to  it  has  occupied  the  whole  cir- 
cumference of  the  bowel,  as  it  does  often  in  tubercular  disease,  and  always 
after  the  separation  of  a  mass  of  invaginated  bowel. 

Another  very  common  sequence  of  ulceration  is  perforation  of  the  in- 
testinal walls  at  the  seat  of  ulceration,  and  the  consequent  communication 
of  the  interior  of  the  bowel  either  with  the  peritoneal  cavity,  or  with  that 
of  some  hollow  viscus.  The  most  frequent  of  these  communications  is 
that  with  the  peritoneum.  Perforation  occurs  more  frequently  in  enteric 
fever  than  in  any  other  kind  of  disease,  taking  place  generally  somewhere 
in  the  lower  three  feet  of  the  ileuni,  and  rarely  in  the  colon.  It  occurs 
occasionally  only  in  the  course  of  tubercular  ulceration  of  the  bowel,  and 
then  also  generally  in  the  lower  part  of  the  ileum.  It  is  induced  some- 
times by  the  constant  fretting  kept  up  by  the  pressure  of  some  hard  irri- 
tating body,  such  as  a  gall-stone  or  some  other  form  of  intestinal  concre- 
tion. Sometimes  it  follows  upon  the  ulceration  and  softening  of  the  mu- 
cous membrane,  which  attend  the  undue  distention  taking  place  often  in 
the  bowel  above  an  impediment.  Sometimes,  again,  it  results  from  the  se]>- 
aration  of  freshly  united  surfaces,  as  in  intussusception.  And  indeed  it 
may  happen  in  the  course  of  any  form  of  ulceration,  or  weakness,  whether 
dependent  on  mere  thinning,  or  softening,  or  ulceration,  or  gangrene.  The 
actual  perforation,  at  least  so  far  as  regards  the  peritoneum,  which  is  al- 
ways the  last  part  to  yield,  is  due  generally,  perhaps  always,  to  laceration. 
And  although  the  result  of  the  lesion  is  general  and,  with  few  exceptions, 


ULCERATION    OF   THE    BOWELS.  57 

rapidly  fatal  peritonitis,  the  lips  of  the  perforation  and  the  contiguous 
portion  of  bowel  are  almost  always  found  adherent  by  lymph  to  some 
neighboring  viscus.  Indeed  perforation  into  the  peritoneum  is  sometimes 
staved  off,  or  wholly  prevented,  by  the  previous  occurrence  of  localized 
adhesive  peritonitis.  It  is  by  the  intervention  of  such  adhesion  that  a  per- 
forating ulcer  of  the  bowel  comes  usually  to  communicate  with  some 
neighboring  hollow  viscus.  The  ulcer,  having  first  eaten  its  way  through 
the  thickness  of  the  parietes  of  the  bowel,  next  perforates  the  layer  of 
adhesions,  then  the  walls  of  the  attached  viscus;  and  thus  establishes  a 
more  or  less  free  passage  between  them,  and  permits  a  more  or  less  ready 
interchange  of  contents.  Sometimes  an  abscess-like  cavity  lies  between 
the  two  organs  which  communicate,  and  forms  the  medium  of  their  com- 
munication. Such  communications,  though  generally  perhaps  perma- 
nent, are  not  always  so;  and  their  closure  is  effected  usually  by  the  retreat 
of  the  bowel  from  the  organ  to  which  it  is  adherent,  and  the  consequent 
formation  of  a  hollow  funnel-like  passage  between  them,  which  becoming 
longer  and  narrower,  finally  closes  at  its  narrowest  end,  or  that  furthest 
from  the  bowel.  There  are  probably  none  of  the  abdominal  viscera  be- 
tween which  and  the  bowels  communication  may  not  be  established  by 
means  of  ulceration  beginning  on  the  side  of  the  bowel.  Thus,  not  in- 
frequently, contiguous  portions  of  the  small  intestine  are  found  opening 
into  one  another,  or  small  intestine  into  the  transverse  or  some  other  part 
of  the  colon:  and  thus  the  rectum  or  sigmoid  flexure,  or  even  the  small 
intestine,  may  be  found  to  communicate  with  an  ovary  or  with  the  uri- 
nary bladder;  or  the  duodenum,  and  perhaps  the  transverse  colon  with 
the  gall-bladder;  or  the  stomach  with  the  transverse  colon;  or  again  al- 
most any  part  of  the  intestinal  canal  may  open  through  the  abdominal 
parietes,  forming  a  faecal  fistula,  or  artificial  anus.  In  some  cases  the  per- 
forating ulceration  begins  in  a  diverticulum  of  the  ileum,  or  in  one  of  the 
false  diverticula  occurring  sometimes  in  the  large  intestine.  Mr.  Sydney 
Jones'  records  a  case  in  Avhich  ulceration  of  a  false  div^erticulum  in  the  sig- 
moid flexure  led  to  a  passage  between  that  part  of  the  bowel  and  the 
bladder.  The  results  of  some  of  these  communications  are  perhaps  of  little 
importance;  other  communications,  however,  are  not  only  of  dangerous 
consequence,  but  also  of  much  interest.  Among  these  latter  are  espe- 
cially communications  between  the  colon  and  the  stomach  or  duodenum, 
which  lead  to  the  occasional  or  constant  vomiting  of  actual  faeces,  and  the 
escape  of  undigested  food  into  the  large  intestine;  and  communications 
with  the  urinary  bladder,  which  occasion  the  escape  of  flatus  and  of  faeces 
into  that  viscus,  with  other  consequences  which  are  easy  to  foresee, 

(b)  Ulceration  heginning  froin  tcithoiit. — Ulceration  of  the  bowel  be- 
ginning from  without  occurs  generally  in  connection  with  some  abscess  of 
which  the  intestine  has  been  made  to  form  a  portion  of  the  parieteSv  The 
abscess  is  sometimes  distinctly  peritoneal;  sometimes  occupies  a  viscus. 
which  becomes  adherent  to  the  bowel  at  the  point  where  perforation  is 
about  to  take  place.  Sometimes  the  purulent  matter  infiltrates  the  cellu- 
lar tissue  of  the  mesentery  or  of  some  other  peritoneal  duplicature,  and 
thus  reaches  the  intestinal  walls.  If  the  external  abscess  attacks  a  part 
of  bowel  covered  with  peritoneum,  it  generally  causes  the  erosion  of  that 
membrane  in  the  first  instance  to  a  comparatively  small  extent:  then  the 
matter  undermines  it,  and  accumulates  between  it  and  the  muscular  coat; 
soon  the  muscular  coat  becomes  opaque,  softened,  and  perforated  in  one 

'  Path.  Trans,  vol.  x. 


58  DISEASES    OF   THE   INTESTINES    AND    PERITONEUSI. 

or  more  spots,  when  again  an  accumulation  of  matter  takes  place  between 
the  muscular  and  the  mucous  membranes,  which  latter  then  forms  a  larger 
or  smaller  hemispherical  bulging  towards  the  interior  of  the  bowel,  on  the 
convexity  of  which  ulceration  soon  ensues,  and  the  communication 
between  the  abscess  and  the  bowel  is  completed.  Or  again,  a  hollow  vis- 
cus  may  open  by  ulceration  into  the  bowel,  having  first  caused  adhesion, 
exactly  in  the  same  way  that  the  bowel  opens  into  other  organs.  By  the 
processes  here  indicated,  peritoneal  abscesses  discharge  themselves  into 
various  parts  of  the  bowel;  inflamed  ovarian  tumors  communicate  with  the 
rectum,  sigmoid  flexure,  or  other  parts;  an  ulcerated  gall-bladder,  or  an 
abscess  of  the  liver,  perforates  the  duodenum  or  transverse  colon;  an  ab- 
scess of  the  kidney  or  other  form  of  retro-peritoneal  abscess  opens  on  the 
one  side  into  the  ascending  colon  and  caecum,  on  the  other  into  the 
descending  colon,  or,  by  burrowing  beneath  the  peritoneum,  reaches  the 
rectum,  and  perforates  that.  In  a  similar  way,  too,  an  abscess  of  the 
liver,  or  even  an  empyema,  may  empty  itself  into  the  cjecum  or  some  other 
part  of  the  large  intestine,  in  or  just  above  the  pelvis. 

In  a  few  instances,  tubercular  deposits  commencing  at  the  peritoneal 
surface  gradually  invade  the  whole  thickness  of  the  bowel,  forming  here 
and  there  large  knots  of  tubercular  infiltration  of  the  intestinal  walls, 
which  gradually  softening  lead  to  the  ulceration  of  the  mucous  surface 
over  them,  to  the  formation  of  a  tubercular  abscess,  and  even  to  a  com- 
munication between  the  interior  of  the  bowel  and  the  cavity  of  the  abdo- 
men. 

It  may,  perhaps,  be  added  here,  that  malignant  disease  of  the  bowel 
not  only  causes  ulceration  of  the  mucous  surface,  but  not  infrequently 
])roduces  perforation  into  the  abdomen,  and  is,  perhaps,  the  most  frequent 
cause  of  complex  and  unusual  communications  between  neighboring  cavi- 
ties, and  these  and  the  external  surface. 

II.  Symptoms. — The  symptoms  which  ulceration  of  the  bowels  pro- 
duces are  so  constantly  associated  with  the  symptoms  of  those  morbid 
states  of  system  on  which  the  ulceration  depends,  and  are  so  frequently 
mixed  up  with  symptoms  due  to  the  various  complications  which  follow 
upon  ulceration,  that  we  have  seldom  the  opportunity  of  studying  them 
in  their  simple  form;  and,  indeed,  if  we  omit  all  reference  to  the  symp- 
toms of  its  complications,  we  leave  very  little  to  be  said  upon  the  sj'mp- 
tomatology  of  ulceration.  It  may  be  stated  generally,  that  ulceration  of 
the  bowels  is  attended  in  the  first  instance  with  more  or  less  marked  feb- 
rile symptoms,  which  assume,  if  the  disease  become  chronic,  a  distinctly 
and  indeed  typical  hectic  character;  that  the  affected  bowel  is  more  or 
less  tender  on  pressure,  a  character  which  is  especially  observable  if  the 
ulceration  be  extensive,  or  if  it  occupy  the  caecum  and  other  parts  of  the 
large  intestine;  that  there  is  some  impairment  of  nutrition  marked  by 
emaciation  and  debility,  and  feebleness  of  circulation;  and  that  there  is, 
above  all,  something  abnormal  in  the  action  of  the  bowels  and  in  the 
evacuations.  The  stools  in  ulceration  of  the  bowels  are  generally  liquid, 
contain  an  abnormal  quantity  of  the  fluid  secretions  of  the  bowels,  and 
not  infrequently  more  or  less  blood;  they  are,  moreover,  often  pea-soup- 
like in  color  and  consistence,  and  much  more  foetid  than  in  health;  fur- 
ther, they  are  usually  passed  much  more  frequently  than  natural,  and  the 
patient  suffers  from  frequent  colicky  pains  and  from  tenesnnis.  But  all 
these  symptoms  are  liable  to  much  modification,  and  one  or  even  all  of 
them  may  be  absent.  Thus,  sometimes  ulceration  is  present,  especially  if 
it  occur  high  up  in  the  small  intestine,  without  occasioning  any  obvious 


ULCERATION    OF   THE    BOWELS.  59 

disturbance  of  the  bowels.  I  recollect  very  well  the  case  of  a  man  who 
died  from  gradually  increasing  emaciation  and  debility,  with  no  symptoms 
sufficiently  characteristic  to  point  to  any  one  organ  as  the  seat  of  the  dis- 
ease, and  in  whom  after  death  the  only  visible  lesion  was  pretty  extensive 
chronic  ulceration  at  the  upper  part  of  the  ileum.  The  bowels,  indeetJ, 
may  be  constipated  from  first  to  last,  as  we  now  and  then  observe  in  cases 
of  enteric  fever,  and  as  happened  in  a  case  of  extensive  ulceration  of  the 
large  intestine  which  I  have  quoted  in  another  article,  and  in  which  death, 
and  probably  the  ulceration  itself,  were  due  to  simple  constipation.  Ulcer- 
ation of  the  larger  bowel  is  much  more  constantly  associated  with  the  pas- 
sage of  frequent  and  thin  evacuations  than  is  ulceration  of  the  small 
intestine  :  these  may  be  purely  diarrhceal  when  the  upper  part  of  the 
large  intestine  is  alone  involved,  but  assume  a  more  and  more  decidedly 
dysenteric  character  in  proportion  as  the  ulceration  affects  its  lower  part ; 
in  which  latter  condition  the  evacuations,  though  frequent  and  passed 
with  extreme  tenesmus,  are  scanty,  mucous,  and  often  sanguinolent,  and 
occasionally  only  containing  a  little  true  fsecal  matter.  It  is  in  this  dys- 
enteric form  of  disease,  moreover,  that  the  evacuations  become  most  offen- 
sive, the  foetor  being  sometimes,  even  though  no  gangrene  be  present, 
putrid  and  almost  insufferable.  Besides  the  slight  oozing  of  blood  which 
tinges  the  evacuations  in  diarrhoea  of  a  dysenteric  character,  haemorrhage 
to  a  considerable  amount  sometimes  takes  place,  haemorrhage  which  may 
be  continuous  or  recurrent,  and  sufficient  in  quantity  to  destroy  life. 
This  accident  is  not  very  infrequent  either  in  enteric  fever  or  dysentery, 
and  occasionally  results  from  the  perforation  of  a  comparatively  large 
vein  or  artery.  There  is  little  to  add,  even  in  regard  to  the  diarrhoea 
which  attends  tubercular  disease  of  the  bowels,  excepting  that  as  the  in- 
testinal disease  is  mostly  a  progressive  one,  the  diarrhoeal  symptoms, 
having  once  declared  themselves,  tend  to  become  progressively  more  and 
more  severe,  and  that  it  is  for  the  most  part  in  those  cases  of  phthisis 
which  are  attended  with  intestinal  complication  that  the  emaciation  is 
most  rapid  and  becomes  most  extreme.  This  is  not  the  place  to  discuss 
the  various  symptoms  which  are  caused  by  stricture,  and  by  perforation  of 
the  bowel,  and  by  the  communication  of  the  bowel  with  other  organs,  nor 
to  enter  upon  the  description  of  those  symptoms  which  attend  typhoid  or 
dysenteric  ulceration. 

III.  Treatment. — Tlie  Th'eatment  of  ulceration  merges  in  the  treat- 
ment of  the  various  diseases  with  which  it  is  connected,  and  admits,  in- 
deed, of  but  little  independent  remark.  But  putting  all  its  complications 
out  of  the  question,  our  aim  in  the  treatment  of  ulceration  would  seem  to 
be,  first,  to  promote  the  healing  of  the  ulcer,  and  to  prevent,  as  far  as  pos- 
sible, the  local  mischances  which  are  apt  to  follow;  second,  to  check  the 
abdominal  discomfort  and  the  diarrhoea  which  so  rapidly  weaken  the 
patient;  and  third,  to  support  his  strength  directly  by  all  means  at  our 
disposal.  Whether  there  are  any  medicines  which  are  capable  of  being 
made  to  act  directly  on  an  ulcer  seated  at  a  distance  from  either  outlet 
may  be  a  matter  of  doubt;  still,  from  our  knowledge  of  what  drugs  are 
useful  in  ulcers  of  the  stomach  and  of  the  lower  end  of  the  large  intestine, 
we  are  justified  at  least  in  hoping  that  some  benefit,  however  infinitesimal, 
may  result  from  the  employment  of  the  same  medicines  in  the  treatment 
of  the  deeper-seated  disease.  On  these  grounds,  bismuth,  nitrate  of  sil- 
ver, iron,  copper,  the  mineral  acids  and  other  remedies,  have  been  fre- 
quently employed,  and  often  with  apparent  benefit.  But  rest,  which  is 
so  useful  an  adjunct  in  the  treatment  of  so  many  diseases,  is  of  inestima- 


GO  DISEASES    OF   THE    INTESTINES    AND   PERITONEUM. 

ble  value  in  the  treatment  of  ulceration  of  the  bowels.  The  violent  and 
frequent  peristaltic  movements  and  writhings  which  the  ulcers  themselves 
give  rise  to,  tend  obviously  to  prevent  them  from  healing,  and  add  greatly 
to  the  danger  of  perforation;  purgative  medicines  should  therefore  be  en- 
tirely, or  at  least  as  much  as  possible,  avoided,  and  further,  the  exalted 
peristaltic  movements  which  attend  the  disease  should  be  restrained.  For 
this  purpose  various  astringent  medicines  may  be  used, — lime,  tannic  acid, 
chalk,  and  vegetable  astringents;  but  far  more  useful  than  these,  as  a  rule, 
is  opium,  in  one  or  other  of  its  various  preparations.  There  are  probably 
few  simple  combinations  more  generally  useful  than  the  aromatic  powder 
of  chalk  and  opium,  and  the  compound  kino  powder.  But  it  is  well  to 
bear  in  mind  that  opium  cannot  always  be  taken  in  these  cases.  Chronic 
ulceration  of  the  bowels  is  often  attended  with  an  irritable  condition  of 
the  mucous  membrane  of  the  mouth  and  stomach,  manifested  by  dryness, 
soreness,  and,  perhaps,  cracking  of  the  tongue,  and  heat  at  the  stomach, 
with  nausea — conditions  which  the  use  of  opium  unfortunately  often  in- 
tensifies. If  opium  then  cannot  be  administered,  astringent  medicines 
with  carminatives  must  be  alone  employed;  or  some  other  form  of  seda- 
tive, such  as  hyoscyamus,  belladonna,  Indian  hemp,  hydrocyanic  acid,  &c, 
must  be  resorted  to.  Opium  may  often  be  given  with  advantage  in  the 
fonn  of  suppository  or  of  enema.  It  need  scarcely  be  added  that  it  is 
never  desirable  by  these  means  to  produce  prolonged  constipation;  and 
that  to  obviate  this  contingency,  either  the  medicines  wliich  have  pro- 
duced it  must  be  left  off  or  given  in  diminished  doses,  or  simple  enemata 
must  be  employed.  It  is  obvious  that  the  various  measures  which  have 
just  been  enumerated,  while  they  check  peristalsis,  act  with  equal  efficacy 
in  fulfilling  the  second  indication  of  treatment, — namely,  the  arrest  of 
diarrhoea.  Our  third  and  last  object,  the  maintenance  of  the  patient's 
strength,  must  be  attained  by  the  exhibition  of  tonic  medicines,  and  the 
careful  administration  of  food  and  stimulants.  The  form  of  tonic  to  be 
given  must  obviously  be  made  to  accord  with  the  treatment  selected  to 
restrain  peristalsis  and  diarrhoea;  it  must  also  be  adapted  to  the  condi- 
tion of  the  patient,  as  regards  his  general  health  and  his  digestive  func- 
tions. In  the  same  way  the  diet  must  be  regulated  :  nothing  should  be 
permitted  which  is  known  to  disagree  with  the  patient;  everything  should 
be  well  cooked,  well  masticated,  and  easy  of  digestion,  and  food  should  be 
given  in  moderate  quantities,  and  at  regular  if  not  frequent  intervals. 
Farinaceous  foods  are  in  many  cases  most  suitable,  but  eggs,  fish,  and 
fowl  may  often  be  used  with  great  advantage.  Butchers'  meat  is  some- 
times wholly  inadmissible.  For  stimulants,  nothing,  perhaps,  is  better,  in 
a  general  way,  than  brandy  and  water,  sherry,  or  madeira. 

For  reasons  which  are  sufficiently  apparent,  and  which  have  indeed 
been  already  indicated,  the  remarks  on  the  treatment  of  ulceration  are 
intentionally  meagre,  and  point  rather  to  general  principles  than  to  details. 


CANCEROUS  AND  OTHER  GROWTHS  OF  THE 
INTESTINES. 

By  John  Syer  Bristowe,  M.D.,  F.R.C.P. 


(1)  Cancerous  disease,  to  any  serious  extent,  much  more  rarely  affects 
the  intestines  than  the  stomach,  and  the  small  intestine  much  more  rarely 
than  the  large.  Of  all  parts  of  the  intestinal  canal,  the  rectum  seems  to 
be  the  most  frequently  thus  affected,  the  sigmoid  flexure  next.  Yet  the 
bowels  are  very  often  the  seat  of  a  trivial  amount  of  cancerous  deposit; 
for  peritoneal  cancer,  which  is  a  not  uncommon  form  of  disease,  is  almost 
always  attended  with  more  or  less  involvement  of  their  serous  surface. 
Cancer  rarely  originates  in  the  substance  of  the  intestinal  walls;  but  in- 
volves them  by  extension  from  the  serous  membrane,  from  the  mesenteric 
and  other  abdominal  lymphatic  glands,  from  the  connective  tissue  of  the 
lesser  omentum,  venter  ilei,  or  pelvis,  or  from  the  stomach,  or  the  pelvic 
genito-urinary  organs,  especially  the  uterus  and  vagina.  When  commenc- 
ing from  the  peritoneum,  it  makes  its  appearance  in  that  membrane  in  the 
form  of  lenticular  or  tubercular  elevations,  which  tend  to  increase  in  num- 
ber and  to  enlarge,  and  then  to  coalesce,  so  as  to  form  a  tolerably  smooth 
or  somewhat  nodulated  lamina  of  various  thickness.  Generally  the  can- 
cerous deposits  appear  first,  and  are  most  abundant  in  the  vicinity  of  the 
lines  along  which  the  peritoneum  leaves  the  bowel;  and  whether  the  dis- 
ease begins  in  the  peritoneum  or  in  the  substance  of  the  mesentery  and 
similar  processes  (but  especially  in  the  latter  case),  the  sub-serous  connec- 
tive tissue  becomes  largely  infiltrated  and  thickened,  and  the  bowel  firmly 
■fixed  to  it  or  set  as  it  were  in  it.  It  is  naturally  in  the  loose  tissues  around 
the  lower  part  of  the  rectum,  the  caecum,  and  the  duodenum,  that  the  de- 
velopment of  sub-peritoneal  cancer  is  most  abundant;  and  sometimes  these 
parts  are  thus  reduced  to  mere  channels,  excavated,  as  it  were,  in  the  sub- 
stance of  a  solid  mass.  Cancerous  disease  of  the  outer  surface  of  the 
bowel  may  be  almost  universal;  or  it  may  affect  tracts  of  bowel  of  various 
lengths;  or,  again,  a  band  of  cancerous  deposit  may  encircle  the  bowel  at 
some  point  (generally,  in  this  case,  the  lower  part  of  the  large  intestine), 
while  merely  a  few  isolated  cancerous  nodules  are  scattered  at  distant 
intervals  over  other  parts  of  the  peritoneum. 

Cancer  beginning  on  the  outer  surface  tends  no  doubt,  sooner  or  later, 
to  invade  the  tissues  internal  to  it;  but  although  there  is  certainly  a  great 
tendency  in  it  to  spread  laterally,  it  is  remarkable  how  frequently,  even 
in  extensive  peritoneal  cancer,  the  muscular  and  mucous  coati  escape. 
When  the  disease  extends  inwards,  growths  of  cancer,  continuous  with 
those  placed  externally,  perforate  the  muscular  coat,  which  generally  be- 
comes at  the  same  time  increased  in  thickness  and  marked  with  vertical 
bands,  of  which   some  appear  to  be  simply  fibrous.     Subsequently  the 


62  DISEASES   OF  THE   INTESTINES   AND   PERITONEUM. 

disease  invades  the  sub-mucous  tissue,  in  which  it  spreads  both  laterally 
and  vertically,  forming  a  more  or  less  well-defined,  rounded,  or  nodulated 
tumor,  at  first  beneath  the  mucous  membrane  which  is  still  movable  over 
it,  then  involving  that  membrane,  and  rendering  it  smooth  and  fixed.  At 
this  stage  nodules  of  cancer,  having  no  apparent  continuity  with  preexist- 
ing cancerous  masses,  are  apt  to  appear  in  the  substance  of  the  mucous 
membrane.  Then  soon  ulceration  takes  place,  which  is  sometimes  pre- 
ceded by  the  formation  of  a  kind  of  false  membrane  on  the  diseased  sur- 
face, and  is  often  attended  with  more  or  less  sloughing  of  the  cancerous 
mass.  The  diseased  tract  thus  becomes  excavated,  and  then  presents 
either  a  hard,  smooth,  cupped  surface,  or  one  in  which  fungous  granula- 
tions are  intermixed  with  sloughing  hollows;  the  edges  being  thickened, 
and  either  callous  and  tolerably  smooth,  or  sprouting  out  with  cancerous 
excrescences. 

The  direct  ill-effects  of  cancer  of  the  bowels  are  various.  In  some 
cases,  especially  when  the  mucous  membrane  is  involved  in  some  consid- 
erable area,  diarrhoea  of  a  more  or  less  uncontrollable  character  contrib- 
utes to  hasten  the  patient's  death;  in  other  cases,  and  generally  when 
the  large  intestine  is  the  seat  of  disease,  and  a  limited  portion  of  bowel 
only  is  involved,  stricture  takes  place;  in  other  cases,  serious  or  fatal 
haemorrhage  arises,  either  from  the  general  surface  of  an  ulcer,  or  in  con- 
sequence of  the  erosion  of  some  large  vessel  in  the  progress  of  the  ulcera- 
tion; and  in  other  cases,  again,  the  bowel  opens  into  the  peritoneum,  and 
extravasation  of  its  contents  and  peritonitis  ensue,  or  communications 
take  place  between  it  and  other  portions  of  bowel,  or  other  organs,  giving 
rise  to  special  symptoms  of  more  or  less  urgency  and  danger. 

The  different  kinds  of  cancer  affect  the  bowels  in  much  the  same  pro- 
portion as  they  affect  the  stomach;  and  present,  as  they  do  in  the  latter 
organ,  certain  specific  peculiarities  which  may  be  briefly  adverted  to. 
Scirrhus  tends  to  produce  contraction  of  the  parts  which  it  involves,  and 
is  especially  that  form  of  cancer  which  causes  stricture.  The  ulcer  which 
it  yields  is  very  often  smooth  and  excavated;  but  sometimes,  when  scir- 
rhus extends  from  the  outer  part  of  the  bowel  to  the  mucous  membrane,  it 
assumes  in  the  latter  situation  the  character  of  soft  cancer,  and  forms 
there  projecting  growths,  or  an  ulcer  with  a  tendency  to  sprout.  EJnceph- 
aioid  cancer  presents  various  degrees  of  softness  and  vascularity,  and 
rarely  causes  obstruction  of  the  bowel,  except  by  the  formation  of  a 
tumor,  or  series  of  tumors,  springing  from  its  mucous  aspect  and  project- 
ing into  its  cavity.  The  tumors  are  rounded,  or  lobulated,  or  even  vil- 
lous, and  have  a  great  tendency  to  ulcerate  or  slough,  and  bleed.  The 
melanotic  variety  of  encephaloid  rarely  affects  the  intestines  except  sec- 
ondarily, and  in  the  form  of  minute  discrete  black  spots,  scattered  for 
the  most  part  over  the  peritoneal  surface.  Epithelial  cancer  occasionally 
involves  the  rectum  by  spreading  to  it  from  the  uterus  and  vagina;  and 
occasionally,  also,  arises  independently  in  the  lower  part  of  that  tube.  I 
am  not,  however,  aware  that  it  ever  originates,  or  is  indeed  found,  in 
other  parts  of  the  intestinal  canal.  Colloid  cancer,  or  (if  it  be  preferred) 
colloid  disease,  affects  the  bowel  usually  like  scirrhus  and  encephaloid, 
from  the  peritoneal  surface,  and  gradually,  like  them  extending  through 
the  intestinal  walls,  spreads  pretty  widely  in  the  substance  of  the  mucous 
membrane,  at  the  surface  of  which  it  appears  in  the  form  of  groups  of 
njinute  vesicles,  reminding  one  of  patches  of  herpes  or  of  eczema,  or  (if 
the  fibroid  element  be  in  excess)  in  the  form  of  whitish  wheals  not  unlike 
tliose  of  scirrhus.     These  become  eroded,  or  more  or  less  orcavated,  but 


CANCEROUS   AND    OTIIER    GROWTHS    OF   THE   INTESTINES.       63 

remain  pretty  smooth,  and  secrete  in  abundance  the  transparent  glairy 
fluid,  with  which  the  interstices  of  colloid  material  are  filled.  Colloid 
cancer  comparatively  rarely  involves  the  mucous  membrane  of  the  bowel, 
at  any  rate  to  a  serious  extent.  It  sometimes  appears  in  the  csecum,  sig- 
moid flexure,  or  rectum,  as  a  primary  disease.  Mr.  W.  Adams'  records  a 
case  in  which  a  colloid  tumor,  as  large  as  the  fist,  springing  from  the 
posterior  part  of  the  rectum,  projected  into  it,  and  caused  symptoms  of 
stricture. 

It  is  difficult,  if  not  impossible,  to  discuss  the  symptoms  and  treat- 
ment of  intestinal  cancer  apart  from  the  symptoms  and  treatment  of 
abdominal  cancer  generally,  or  from  those  of  cancer  of  the  stomach  and 
rectum,  or  from  those  of  its  chief  local  consequences, — namely,  obstruc- 
tion and  perforation ;  it  is,  moreover,  needless,  for  these  are  all  considered 
at  length  in  other  articles. 

(2)  Fibroid  infiltration  and  thickening,  identical  with  the  fibroid  form 
of  so-called  "  scirrhous  "  pylorus,  is  met  with  occasionally  in  the  bowels, 
where  also  it  constitutes  one  form  of  "scirrhus."  Its  chief,  perhaps  only, 
seats  are  the  sigmoid  flexure  and  rectum,  where  it  produces  results  re- 
sembling in  almost  every  particular  those  which  have  been  described  as 
belonging  to  true  scirrhus.  It  seems,  however,  to  differ  from  that  in  its 
purely  local  character,  in  the  absence  of  all  secondary  deposits,  as  well  as 
in  its  elementary  constitution. 

(3)  Villous  growtJis  are  of  occasional  occurrence  in  the  large  intestine, 
particularly  in  the  sigmoid  flexure  and  rectum.  They  generally  occupy  a 
limited  and  well-defined  area,  which  sometimes  amounts  to  three  or  four 
square  inches  or  more,  and  sometimes  encircles  the  gut.  The  portion  of 
the  parietes  corresponding  to  the  villous  surface  is  always  infiltrated  and 
thickened  to  a  greater  or  less  degree  with  a  kind  of  fibroid  material, 
which  forms  the  basis  from  which  the  villous  excrescences  spring.  Tlio 
mucous  coat  and  sub-mucous  tissue  are  the  parts  principally  thus  affected, 
and  sometimes  indeed  grow  out  into  a  tumor  with  a  constricted  neck. 
The  villi  are  abundant  and  close-set,  easily  distinguishable,  especially  if 
the  tumor  be  floated  in  water,  often  of  considerable  length,  conical,  cylin- 
drical or  club-shaped,  and  branching.  As  we  have  already  seen,  villous 
outgrowths  are  sometimes  distinctly  cancerous;  but  certainly  most  of 
those  which  have  been  met  with  in  the  large  intestine  seem  clearly  to 
liave  been  of  a  benign  character.  The  presence  of  a  villous  tumor  some- 
times causes  hfemorrhage  from  the  bowels,  or  dysenteric  diarrhoea;  but  its 
ultimate  tendency  seems  always  to  produce  obstruction.  In  most  of  the 
recorded  cases  death  has  been  the  result  of  stricture.  Occasionally,  when 
the  growth  is  situated  but  a  short  distance  from  the  anus,  it  admits  of 
removal  by  operation. 

(4)  Polypi,  or  outgrowths  of  a  non-malignant  character,  are  not  very 
infrequently  discovered  post  mortem  attached  to  the  intestinal  mucous 
membrane,  especially  to  that  of  tiie  lower  part  of  the  ileum,  ascending  colon, 
and  rectum,  and  are  someti.mes  present  here  in  vast  numbers.  They  seem 
generally  to  resemble  ordinary  cutaneous  fibro-cellular  or  molluscous 
tumors,  and  consist,  like  them,  of  an  outgrowth  of  connective  tissue  in- 
vested in  a  layer  of  mucous  membrane,  which  still  for  the  most  part  pre- 
sents its  normal  structure.  It  seems  not  improbable  that  they  occasion- 
ally originate  in  connection  with  the  edges  of  ulcerated  patches;  but  they 
doubtless  more  frequently  arise  independently  of  any  discoverable  pre- 

'  Path.  Soc.  Trans,  vol.  i. 


64  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

exist  in  j^  cause.  In  an  early  stage  they  form  mere  rounded  bead-like 
excrescences,  looking  like  enlarged  solitary  glands;  but  they  soon  elon- 
gate, and  generally  at  the  same  time  increase  in  some  degree  in  other 
dimensions.  When  thoroughly  developed,  they  form  for  the  most  part 
cylindrical  outgrowths  from  about  a  quarter  of  an  inch  to  an  inch  in 
length,  and  from  the  thickness  of  a  probe  up  to  that  of  a  director,  with 
extremities  which  are  sometimes  bulbous  and  cauliflower-like,  and  then 
highly  vascular,  and  tending  to  bleed.  Sometimes  they  occur  in  groups 
of  two  or  three,  or  twc  or  three  spring  from  the  same  pedicle.  In  the 
lower  part  erf  the  ileum,  similar  bodies,  but  of  a  flatter  and  more  leaf-like 
character,  appear  occasionally  to  be  produced  by  mere  elongation  of  por- 
tions of  valvulte  conniventes.  The  polypi  which  have  just  been  described 
are,  as  far  as  I  know,  of  little  or  no  consequence;  they  occur  in  persons 
of  all  ages  and  of  both  sexes,  and  do  not  seem  to  cause  any  symptoms. 
Solitary  polypi,  however,  sometimes  attain  a  large  size,  and  may  then  pro- 
duce great  inconvenience,  if  not  more  serious  mischief.  Pedunculated 
fibro-cellular  polypi  from  any  size  up  to  that  of  a  small  pear  are  now  and 
then  met  with  in  the  ileum,  and  are  supposed  to  occasionally  cause  intus- 
susception; their  most  common  seat,  however,  is  the  rectum,  in  which 
situation  they  cause  irritation  of  the  bowels,  tenesmus,  more  or  less  copi- 
ous bleeding,  and  other  discomforts.  These  solitary  tumors  are  generally 
pretty  smooth,  but  are  sometimes  lobulated  or  even  warty,  and  mostly 
abundantly  vascular  on  the  surface. 

(5)  Other  growt/iS  in  the  intestinal  walls  are  of  no  practical  import- 
ance; they  are  rare,  are  not  productive  of  symptoms,  and  do  not  there- 
fore call  for  description.  Among  them  may  be  enumerated  circumscribed 
sub-mucous  deposits  of  fat;  small  cysts  in  the  same  situation;  erectile 
tumors  (Rokitansky  '  considers  the  polypi  above  described  as  being  erec- 
tile) ;  and  glaridular  tumors  (in  two  cases  '^  I  have  met  with  tumors  in  the 
small  intestine  which  resembled  the  pancreas  accurately  in  structure). 
Lastly,  it  may  be  mentioned  that  calcareous  matter  is  sometimes  deposited 
in  small  masses,  either  on  the  peritoneal  or  mucous  surface,  or  in  the  sub- 
stance of  the  intestinal  walls. 

'  Path.  Anat.  Syd.  Soc.  Trans,  vol.  ii. 

'  Dr.  Montgomery,  Path.  Soc.  Trans,  vol.  xii  p.  130. 


DISEASES  OF  THE  C^CUM  AND  APPENDIX 
VERMIFORMIS. 

By  Jomf  Stke  Beistowe,  M.D.,  F.R.C.P. 


The  caecum  and  its  appendix  are  liable,  in  a  greater  or  less  degree,  to 
all  those  affections  which  have  been  described  as  incidental  to  the  intes- 
tinal canal  generally.  But  while  some  occur  here  comparatively  rarely, 
or  are  of  trivial  consequence  when  they  do  occur,  others  (owing  partly  to 
the  connections  and  position  of  the  organs,  partly  to  their  capacity  and 
shape,  and  partly  to  their  structural  peculiarities)  involve  them  with  e:c- 
ceptional  frequency,  or  induce  results  which  are  characteristic  either  ia 
their  gravity  or  in  some  of  the  other  features  which  they  present. 

I.  Geneeal  Account  of  Diseases  op  C^cum  and  Appendix.- - 
Inflammation  in  its  simpler  forms  affects  the  caecum  at  least  as  frequently 
as  it  affects  any  other  part  of  the  gastro-intestinal  mucous  membrane. 
Dysenteric  inflammation  is  only  less  common  here  than  it  is  in  the  rectum 
and  sigmoid  flexure.  Ulceration  of  a  non-specific  kind  is  perhaps  more 
often  met  with  in  the  caecum  than  in  any  other  named  tract  of  bowel. 
The  ulceration  of  enteric  fever  is  always  more  extensive  and  more  ad- 
vanced in  the  caecum  than  in  the  colon  or  rectum,  and  occurs  in  it  about 
half  arj  frequently  as  it  occurs  in  the  ileum.  Tubercular  disease,  which 
affects  the  large  and  small  intestine  with  equal  frequency,  is  also  generally 
more  severe  in  the  caecum  than  in  other  parts  of  the  large  intestine.  Can- 
cerous diseases  are  not  very  uncommon  in  this  part.  And  again,  the  de- 
generative results  of  chronic  inflammation,  and  of  lardaceous  and  other 
forms  of  deposit,  and  polypoid  growths,  occur  equally  in  the  caecum  and 
in  the  colon  and  lower  part  of  the  ileum.  The  ileo-caecal  valve  and  vej' 
iniform  appendix  are  for  the  most  part  involved  whenever  the  caecum  it 
the  subject  of  any  of  the  morbid  processes  which  have  just  been  enumer 
ated.  The  margins  of  the  valve  are  indeed  not  infrequently  destroyed  by 
ulceration.  And  the  appendix  especially  rarely  fails  to  present  more  or 
less  ulceration  when  typhoid  or  tubercular  deposits  occur  in  other  parts 
of  the  large  intestine. 

Strictures  of  the  caecum  form  (according  to  Dr.  Brinton)  4  per  cent,  of 
fatal  strictures  of  the  large  intestine.  Some  degree  of  contraction  at  th\s 
part  is,  however,  a  good  deal  more  common  than  these  figures  would  seem 
to  indicate.  The  causes  of  contraction  are,  cancerous  or  other  deposit 
or  growth  in  the  walls,  and  the  cicatrization  which  follows  ulceration, 
especially  tubercular  and  dysenteric  ulceration.  Dilatation  of  the  caecum 
occurs  casually,  as  dilatation  occurs  in  other  parts  of  the  intestinal  tract, 
from  the  temporary  accumulation  of  faecal  matters,  or  flatus,  or  both. 
And  it  occurs  also,  as  in  other  situations,  as  a  result  of  obstructive  disease 
in  some  part  of  the  bowel  below  it.  In  this  case  the  dilatation  may  be- 
5 


6Q  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

come  very  great;  and  according  to  circumstances  the  parietes  may  be 
thinned  or  hypertrophied.  It  is  a  point  of  some  importance  that  not  in- 
frequently, even  when  obstruction  is  pretty  low  down,  the  caecum  is  more 
largely  dilated  than  the  length  of  bowel  between  it  and  the  seat  of  ob- 
struction. 

Perforation  of  the  caecum  is  far  from  uncommon.  Sometimes  this 
ensues  on  long-continued  distention,  either  from  thinning,  softening  and 
sudden  laceration,  or  from  the  ulceration  which  so  frequently  attends  dis- 
tention. Sometimes  it  is  caused  by  simple  perforating  ulcer,  or  by  the 
irritation  of  some  foreign  body  which  has  been  swallowed,  has  traversed 
the  small  intestine  safely,  and  has  become  arrested  in  the  caecal  pouch. 
Sometimes  it  occurs  in  the  course  of  dysentery,  enteric  fever,  and  tuber- 
culosis. Sometimes  it  is  a  result  of  cancerous  ulceration.  And  some- 
times it  depends  on  diseases  outside  the  bowel,  such,  for  example,  as  can- 
cer occupying  the  venter  ilei,  or  the  extension  of  a  psoas,  renal,  hepatic, 
pleural,  or  other  abscess.  Perforation  may  take  place  directly  into  the 
peritoneum,  lighting  up  fatal  peritonitis;  or  it  may  establish  a  communi- 
cation between  the  cavity  of  the  bowel  and  the  sub-serous  cellular  tissue 
of  the  venter  ilei,  or  some  adjoining  part,  and  lead  to  the  formation  of  a 
fascal  abscess;  or  again,  it  may  cause  a  communication  with  some  adhe- 
rent coil  of  small  intestine. 

We  can  scarcely  speak  of  stricture  of  the  appendix  vermiformis;  yet 
occasionally,  as  a  result  of  ulcerative  destruction  of  the  mucous  membrane 
or  of  other  morbid  processes,  the  whole  organ  becomes  shrivelled  up  or 
atrophied.  Dilatation,  too,  sometimes  occurs  when  its  orifice  is  obliter- 
ated or  obstructed.  Then  the  appendix  becomes  elongated  and  plump 
^perhaps  as  thick  as  the  little  finger),  presents  often  false  diverticula 
(resembling  on  a  small  scale  those  of  a  sacculated  bladder),  and  is  dis- 
tended with  a  glairy  transparent  fluid,  the  secretion  of  the  mucous  mem- 
brane. Again,  the  appendix  is  apt  to  become  perforated.  This  accident 
may  be  caused  in  any  of  the  several  ways  in  which  the  caecum  itself  be- 
comes perforated.  It  occurs  sometimes  perhaps  as  a  result  of  mere  ordi- 
nary ulceration.  Dr.  Murchison'  records  a  case  in  which  it  happened  in 
the  course  of  tj'^phoid  fever,  but  where  there  was  no  escape  of  fascal  mat- 
ter. Leudet*  states  that  out  of  thirteen  cases  of  perforation  of  the  appen- 
dix, which  he  observed,  six  were  due  to  tuberculosis.  This  statement, 
liowever,  is  certainly  not  in  accordance  with  general  observation.  The 
usual  cause  indeed  of  perforation  is  undoubtedly  the  presence  of  some 
concretion  which,  by  fretting  the  surface  with  which  it  is  in  contact,  ex- 
cites ulceration,  to  which  the  perforation  is  consecutive.  Fsoros  habitu- 
ally find  an  entrance  into  the  appendix;  but  their  entrance  and  escape 
constitute  a  normal  process  on  which  as  a  rule  no  ill  consequences  super- 
vene. Together  with  the  faeces,  however,  insoluble  bodies  of  small  size — 
seeds,  bristles,  pins,  pieces  of  bone,  shot — are  apt  to  enter  the  appendix; 
and  some  of  these,  from  their  pointed  or  angular  form,  or  from  their  size, 
become  retained  and  cause  ulceration.  Perforation  has  been  caused  by 
bristles,  by  pins,  and  by  pieces  of  bone:  and  indeed  it  was  formerly  gen- 
erally believed  that  the  foreign  bodies  causing  perforation  were  all  of  ex- 
ternal origin,  and  for  the  most  part  cherry  or  date-stones,  or  stones  of  a 
similar  character.     There  seems  no  doubt,  however,  that  bodies  of  this 

'  Path.  Trans,  vol.  xvii.  p.  137. 

•  Archiv.  Gen.  Aug.  and  Sept.  1859,  and  New  Sydenham  Society's  Year  Book  for 
1860. 


DISEASES  OF  THE  CMCViS.  AND  APPENDIX  VERMIFORMIS.       67 

bulk  rarely  find  their  way  into  the  appendix,  and  that  what  have  been 
mistaken  for  them  have  been  concretions  resembling  them  somewhat  in 
size  and  shape,  but  differing  from  them  in  origin  and  in  constitution.  The 
concretions  generally  met  with  vary  from  perhaps  the  size  of  a  small  pea 
to  that  of  a  date-stone:  they  are  sometimes  of  waxy  consistence  and  lus- 
tre throughout;  sometimes  brownish,  for  the  most  part  faecal,  and  lami- 
nated; sometimes  again  composed  almost  entirely  of  earthy  phosphates; 
they  consist  obviously  of  the  admixture,  in  unequal  proportions,  of  ordi- 
nary faecal  matters  and  of  the  secretions  from  the  mucous  membrane  of 
the  appendix,  and  have  obviously  formed  in  the  situation  in  which  they 
are  found,  either  round  a  nucleus  of  solid  matter  which  has  been  first  pre- 
cipitated and  concreted  there,  or  round  some  comparatively  small  body  of 
extraneous  origin.  Sometimes  two  or  three  of  these  concretions  are  pres- 
ent at  the  same  time.  Perforation  of  the  appendix  occurs  at  any  part, 
sometimes  at  or  near  its  base,  sometimes  at  its  point  or  within  half  an  inch 
of  it,  sometimes  again  in  some  intermediate  spot.  The  resulting  orifice 
varies  in  shape  and  size.  Perforation  may  take  place  directly  into  the 
peritoneal  cavity,  causing  generally  acute  and  rapidly  fatal  peritonitis, 
sometimes  a  circumscribed  peritoneal  abscess;  or  actual  perforation  may 
be  preceded  by  adhesion  of  the  appendix  to  neighboring  parts,  and  the 
formation  of  a  limited  abscess  either  among  the  adhesions  or  in  the  sur- 
rounding structures. 

It  may  be  added  here,  in  order  to  complete  our  summary  of  diseases 
incidental  to  the  caecum  and  appendix:  that  the  most  common  form  of 
intussusception,  and  the  most  frequent  in  children,  is  that  in  which  the 
caecum  is  engaged;  that  the  caecum  is  occasionally  the  subject  of  internal 
strangulation,  and  that  more  frequently  its  appendage  takes  part  in  the 
production  of  strangulation  of  other  parts  of  the  intestine;  and  lastly, 
that  the  caecum  and  its  appendage,  together  or  separately,  are  not  very 
infrequently  contained  in  an  ordinary  hernial  sac. 

II. — Ulceeation  and  Perfobation  of  the  C^cum  AST)  Vermiform 
Appendix:. — (a)  Pathology. — The  terms  "  Typhlitis  "  and  "  Perityphlitis," 
— the  former  signif3dng  inflammation  of  the  walls  of  the  caecum,  the  latter 
inflammation  in  the  tissues  surrounding  the  caecum, — are  used  frequently, 
though  somewhat  vaguely  and  indiscriminately;  but  I  believe  are  generally 
applied  to  those  cases  in  which  there  is  perforative  ulceration  either  of 
the  csecum  or  of  its  appendix,  and  in  which,  therefore,  there  is  either 
limited  suppuration  in  the  neighborhood  of  these  parts,  or  sudden  peri- 
tonitis. The  perforation  in  the  great  majority  of  cases,  no  doubt,  occurs 
in  the  appendix  vermiformis:  sometimes,  however,  it  occurs  in  the  caecum 
itself,  beginning  there  generally  from  ulceration  of  the  mucous  membrane, 
but  occasionally  from  an  abscess  situated  upon  its  outer  surface.  The 
results  which  ensue  have  already  been  briefly  enumerated. 

In  some  instances  the  ulcer  perforates  that  portion  of  the  bowel  which 
corresponds  to  the  mesenteric  attachment,  or,  if  occurring  elsewhere  in 
the  bowel,  the  area  in  which  perforation  is  about  to  take  place  becomes 
adherent  to  some  viscus  in  the  vicinity,  or  to  some  portion  of  the  parietes 
of  the  true  or  false  pelvis.  The  morbid  process  may  stop  at  that  point; 
or  the  escape  of  faecal  matter  and  flatus  into  and  among  the  tissues  may 
lead  to  the  formation  of  an  abscess,  with  more  or  less  surrounding  inflam- 
mation and  induration.  In  the  latter  event  the  abscess  usually  enlarges 
pretty  rapidly,  and  in  enlarging  takes  a  course  dependent  more  or  less  on 
its  original  position,  in  one  case  descending  into  the  pelvis,  and  opening 
perhaps  into  the  rectum,  in  another  passing  out  with  the  pyriformis  muscle 


63  DISEASES    OF   THE   INTESTINES   AND    PEEITONEUM. 

and  presenting  in  or  below  the  buttock,  in  another  forming  a  lump  in  the 
groin  immediately  above  Poupart's  ligament,  or  passing  along  the  inguinal 
canal  towards  the  scrotum,  or  along  the  psoas  and  iliacus  muscles  into  the 
upper  part  of  the  thigh.  But  indeed,  when  once  an  abscess  has  formed, 
although  it  may  tend  as  a  rule  to  elect  one  of  several  courses,  there  is 
scarcely  any  conceivable  direction  which  under  certain  circumstances  it 
may  not  take.  No  doubt  it  generally  presents  itself  in  the  groin  as  a 
hardness  or  lump  superficial  to  the  position  which  the  caecum  normally  oc- 
cupies. An  abscess  of  this  kind  may  empty  itself  and  become  healed  by 
discharging  its  contents  either  through  the  orifice  in  the  caecum  which 
gave  rise  to  it,  or  through  an  opening  at  any  one  of  the  spots  at  which, 
as  has  been  shown,  it  may  present;  or  having  burrowed  largely  it  may 
form  a  sinus  or  series  of  sinuses  which  never  become  obliterated.  The 
communication  between  the  abscess  and  the  cascum  is  sometimes  main- 
tained, at  other  times  is  more  or  less  speedily  obliterated. 

In  other  cases  the  bowel  ruptures  directly  into  the  peritoneum,  exciting 
at  once  acute  peritoneal  inflammation.  This  may  be  so  severe  as  almost 
directly  to  prove  fatal:  but  in  most  cases  the  patient  survives  sufficiently 
long  to  allow  of  the  more  or  less  complete  obliteration  by  adhesion  of  the 
general  cavity  of  the  peritoneum,  and  the  formation  in  the  vicinity  of  the 
perforated  bowel  of  a  circumscribed  peritoneal  abscess.  It  is  not  improb- 
able that  in  some  cases  the  perityphlitic  abscesses,  the  course  and  progress 
of  which  have  been  already  discussed,  are  really  peritoneal  abscesses. 
And  it  may  be  added  that  the  abscesses  originally  unconnected  with  the 
peritoneum  not  infrequently  open  suddenly  into  it  and  evoke,  as  does  the 
sudden  rupture  into  it  of  the  caecum  or  of  its  appendix,  sudden  and  severe 
inflammation  there. 

The  statistics  of  "  Typhlitis,"  using  this  term  as  expressive  of  all  the 
morbid  conditions  which  have  just  been  described,  are  not  very  easy  to 
obtain.  But  as  regards  the  statistics  of  that  section  of  typhlitis  which 
relates  to  perforation  of  the  caecal  appendage  followed  by  fatal  results, 
they  seem  to  show  very  conclusively  that  this  accident  occurs  chiefly  in 
early  life,  and  much  more  frequently  in  males  than  in  females.  Thus,  in 
ten  cases  analyzed  by  Bamberger,'  eight  were  males,  two  females;  eight 
were  below  thirty  years  of  age,  two  above  thirty.  In  thirty-two  cases 
collected  by  Dr.  Crisp,'  twenty-nine  were  males,  three  females;  five 
were  under  ten  years,  thirteen  between  ten  and  twenty,  seven  between 
twenty  and  forty,  and  seven  between  forty  and  sixty.  And  in  eight 
cases  recorded  in  the  "  Pathological  Transactions "  since  the  publication 
therein  of  Dr.  Crisp's  paper,  five  were  males,  three  females;  and  their 
ages  ranged  from  thirteen  to  thirty-four. 

The  duration  of  typhlitis  must  obviously  be  very  various.  When  the 
perforation  takes  place  directly  into  the  peritoneum,  death  for  the  most 
part  ensues  speedily — generally  indeed  in  from  three  days  to  a  week;  life 
may,  however,  even  in  this  case  be  prolonged  in  consequence  of  the  for- 
mation of  a  circumscribed  peritoneal  abscess,  to  two  or  three  weeks  or 
more,  and  it  is  not  impossible  that  under  the  latter  condition  recovery 
sometimes  takes  place.  In  seven  of  Bamberger's  cases  the  duration  of 
the  illness  varied  between  twenty  and  fifty  days.  But  when  a  fsecal 
abscess  forms  in  the  tissues  in  the  neighborhood  of  the  caecum  no  definite 

I 
'  Ueber  die  Perforation  des  wurmformigen  Anhaogs.  :  Schmidt's  Jahrb.  1859,  vol. 
cL,  p.  184. 

» Path.  Trans,  vol.  x.,  p.  151. 


DISEASES  OF  THE  C^CUM  AND  APPENDIX  VERMIFOKMIS.       GO 

limits  can  possibly  bo  assigned  to  the  duration  of  the  case;  sometimes  tho 
patient  recovers  pretty  speedily;  sometimes,  the  case,  having  got  appar- 
ently into  a  chronic  state,  proves  suddenly  fatal  with  symptoms  of  peri- 
tonitis; sometimes  again  the  patient  lingers  for  months,  or  even  years, 
with  a  constantly  discharging  abscess  or  a  succession  of  abscesses. 

(b)  ISi/mptoms. — The  symptoms  which  attend  and  indicate  typhlitis 
are  mainly  either  those  of  acute  peritonitis,  or  those  of  local  suppuration, 
or  a  complex  of  both.  In  those  cases  in  which  sudden  rupture  takes 
place  into  the  peritoneum,  there  are  very  often  no  premonitory  symp- 
toms whatever;  occasionally,  however,  some  localized  uneasiness  or  pain, 
due  to  the  ulceration  which  is  taking  place,  or  to  some  inflammation  of 
the  peritoneal  surface  corresponding  to  the  seat  of  ulceration,  precedes 
for  a  longer  or  shorter  time  the  violent  outbreak.  The  patient,  while  in 
the  enjoyment  apparently  of  perfectly  good  health,  and  at  the  moment 
probably  of  making  some  muscular  effort,  is  attacked  with  sudden  acute 
pain  in  the  region  of  the  caecum,  followed  speedily  by  collapse,  and  the 
diffusion  of  pain  and  tenderness  over  the  whole  extent  of  the  abdomen. 
The  symptoms  in  fact  of  acute  peritonitis  are  almost  instantaneously  set 
up,  symptoms  which  only  differ  from  those  of  idiopathic  peritonitis  in  the 
suddenness  of  their  invasion  and  the  severity  of  the  collapse,  and  differ  in 
no  degree  from  those  which  attend  rupture  of  the  bowel  from  other 
causes,  rupture  of  the  stomach,  or  rupture  of  the  bladder.  It  is  needless 
to  dwell  on  the  character  of  the  abdominal  pain  and  tenderness,  and  on 
the  tympanitic  condition  of  abdomen  which  ensues,  on  the  dorsal  decubi- 
tus which  the  patient  is  generally  compelled  to  assume,  on  the  quickness 
and  shallowness  of  his  respiratory  acts,  on  his  feebleness  of  pulse, 
shrunken  and  anxious  expression,  and  for  the  most  part  frequent  vomit- 
ings and  hiccough.  But  it  may  be  observed,  that  in  spite  of,  or  rather 
perhaps  in  consequence  of,  the  unbearableness  of  his  pain,  the  patient 
sometimes  assumes  positions  and  makes  contortions  of  his  body  which 
might  seem  to  be  incompatible  with  the  presence  of  acute  peritonitis; 
that  sometimes  the  peritonitic  indications  remain  pretty  strictly  limited 
to  the  neighborhood  in  which  they  commenced,  and  that  very  frequently 
indeed  they  do  not  extend  above  the  line  formed  by  the  transverse  colon; 
and  that  sometimes  as  the  case  proceeds,  even  towards  its  fatal  issue, 
general  peritonitic  symptoms  almost  entirely  subside,  leaving  perhaps  a 
distinct  fulness  and  dulness  and  tenderness,  due  to  the  formation  of  a 
circumscribed  abscess,  in  or  about  the  right  lumbar  or  iliac,  or  the  hypo- 
gastric region. 

In  those  cases  in  which  an  abscess  forms  in  the  neighborhood  of  the 
caecum,  there  are  in  the  first  instance  pain  and  tenderness  in  the  region  of 
the  caecum,  together  with  rigors  and  other  general  symptoms  of  inflam- 
matory fever.  Generally,  too,  there  is  some  distinct  fulness  and  tender- 
ness to  be  felt.  The  symptoms  indeed  are  for  the  most  part  those  which 
might  be  caused  by  suppuration,  of  whatever  origin,  occupying  the  venter 
of  the  ileum.  When  the  abscess  extends  downwards  into  the  pelvis,  or 
remains  deep-seated,  the  case  is  naturally  obscure.  When,  however,  it 
tends  to  point  anteriorly,  we  find  the  fulness  and  hardness  become  grad- 
ually more  and  more  pronounced;  the  fulness  in  fact  grows  into  a  more 
or  less  distinctly  hemispherical  tumor  over  which  the  integuments  become 
oedematous  and  congested.  Sometimes,  even  at  this  stage,  the  swelling 
gradually  subsides  and  disappears,  owing  to  the  abscess  having  dis- 
charged itself  into  the  bowel;  but  more  frequently  it  still  enlarges  and 
ultimately  opens  externally,  discharging  a  greater  or  less  amount  of  foetid 


70  DISEASES   OF   TUE   INTESTINES   AND   PERITONEUM. 

pus,  sometimes  having  a  distinct  faecal  odor,  or  even  obviously  containing 
faecal  matter  and  bubbles  of  gas.  It  must,  however,  be  remembered,  that 
not  infrequently  the  communication  with  the  bowel  has  been  cut  off  be- 
fore the  abscess  opens  externally,  and  that  the  absence  of  ordure  or  of 
gas  does  not  necessarily  show  that  the  abscess  has  not  commenced  in  per- 
foration of  the  bowel.  Sometimes  the  abscess,  after  having  discharged 
itself  externally,  gradually  fills  up,  and  complete  and  permanent  recovery 
takes  place.  Sometimes,  after  it  has  healed  externally  and  appears  to 
have  been  cured,  it  forms  afresh  and  presents  in  the  same,  or  some  other, 
situation.  In  other  cases  it  remains  as  a  permanently  open  fistula,  or  as 
an  artificial  anus.  In  these  latter  cases  symptoms  of  hectic  come  on,  the 
patient  becomes  thinner  and  feebler,  and  though  in  some  cases  life  may 
be  prolonged  for  a  considerable  period,  death  generally  ensues  from  grad- 
ual exhaustion  at  the  end  of  a  few  months,  or  at  the  outside  a  year  or  two. 

There  are,  however,  many  cases  in  which  the  perforation  of  the  bowel 
causes  abscess  in  the  first  instance,  and  peritonitis  subsequently,  either  in 
consequence  of  a  fresh  intestinal  perforation,  or  of  a  rupture  of  the  abscess 
into  the  peritoneum,  or  of  the  mere  extension  of  inflammation  by  con- 
tiguity. These  are  the  cases  in  which,  for  the  most  part,  perforation  of 
the  cajcal  appendix  is  said  to  be  preceded  by  premonitory  symptoms;  and 
there  can  be  no  doubt  that  it  is  chiefly  by  taking  these  into  consideration 
that  cases  of  perforation  of  the  appendix  are  estimated  by  Bamberger 
and  others  to  have  a  duration  so  much  longer  than  we  know  belongs  to 
mere  peritonitis  the  result  of  perforation. 

It  might  naturally  be  supposed  that  any  disease,  affecting  so  important 
a  part  of  the  alimentary  canal  as  the  caecum,  would  be  attended  with  some 
disturbance  of  the  functions  of  that  canal.  It  does  not  appear,  however, 
that  there  is  any  constant  disturbance.  Sickness  is  very  often  entirely 
absent.  Constipation  is  mentioned  as  having  been  present  in  many  cases 
at  or  about  the  time  of  perforation;  but  there  does  not  seem  to  be  any 
definite  connection  between  these  two  conditions.  And  diarrhoua  not 
xmcommonly  supervenes  in  the  course  of  the  disease;  but  this  again  would 
seem  to  be  for  the  most  part  a  mere  accidental  phenomenon. 

There  are  many  diseases,  or  incidents  of  disease,  with  which  typhlitis 
may  be  confounded.  It  may  be  worth  while  briefly  to  call  attention  to 
some  of  the  more  important  of  them.  Acute  peritonitis  of  idiopathic  ori- 
gin may  sometimes,  from  its  suddenness  and  severity,  and  from  its  happen- 
ing to  take  the  lower  part  of  the  abdomen  as  its  starting-point,  be  thought 
to  have  its  origin  in  perforation  of  the  appendix.  So  also  may  the  peri- 
tonitis caused  by  perforation  of  the  bowel  in  enteric  fever,  especially  in 
those  cases  in  which  the  febrile  symptoms  are  slight  and  the  patient  is  not 
compelled  to  give  up  work  until  the  sudden  rupture  takes  place.  The 
same  also  may  be  said  of  all  those  cases  in  which  peritonitis  arises  from 
the  perforation  of  a  hollow  viscus,  or  of  an  hydatid  or  other  abscess,  from 
the  laceration  of  the  cyst  of  tubarian  or  ovarian  pregnancy,  or  from  the 
extension  of  inflammation  from  various  pelvic  organs,  especially  those  of 
the  female.  Again,  the  local  suppuration  which  attends  many  cases  of 
typhlitis  may  in  some  one  or  other  of  its  stages  be  easily  confounded  with 
abscesses  of  other  kinds,  which  form  in,  or  find  their  way  into,  the  region 
of  the  caecum;  among  which  maybe  enumerated,  psoas  abscesses,  aiid 
abscesses  extending  from  the  kidney,  the  spinal  canal,  and  the  pleura.  It 
may  similarly  be  confounded  with  ovarian  tumors  or  inflammation,  with 
cancerous  tumors  of  the  venter  ilei  or  glands  in  the  vicinity  of  the  caicum, 
and  even  under  some  circumstances  with  aneurismal  tumors. 


DISEASES  OF  THE  C^CUM  AND  APPENDIX  VEBMIFORMIS.       7 1 

(c)  Treatment. — The  treatment  of  typhlitis  may  be  dismissed  in  a  few 
words,  not  because  it  is  unimportant,  but  because  it  resolves  itself  into  the 
treatment  of  enteritis  and  the  treatment  of  a  localized  suppuration:  the 
former  of  which  has  been  discussed  elsewhere  in  this  volume;  the  latter 
of  which  is  mainly  a  surgical  question.  As  regards  those  cases  in  which 
there  is  a  direct  communication  between  the  bowel  and  the  peritoneum, 
our  main  reliance  must  be  placed  upon  opium;  which  must  be  adminis- 
tered, partly  with  the  object  of  relieving  pain,  partly  with  the  object  of 
restraining  intestinal  movements  and  preventing  further  escape  of  fajcal 
matters.  For  similar  reasons,  all  purgative  medicines  must  be  most  carefully 
avoided.  In  reference  to  the  employment  of  local  measures,  such  as 
leeching,  fomentation,  and  the  like,  no  special  observations  need  be  made. 
It  is  most  important  of  course  to  administer  nourishment  and  stimulants; 
and  owing  to  the  comparative  absence  of  vomiting,  their  administration 
by  the  mouth  can  for  the  most  part  be  much  more  readily  carried  out  than 
in  cases  of  enteritis  or  of  obstruction.  It  is,  however,  at  the  same  time 
essential  that  the  bowels  should  not  be  overloaded,  and  therefore  that  the 
food  which  is  thus  given  should  be  nutritious,  capable  of  easy  digestion 
and  absorption,  and  given  in  small  quantities  at  frequent  intervals.  But 
here  indeed,  as  in  many  other  cases  of  stomach  and  bowel  disease,  it  is 
important  to  consider  how  far  we  may  supplement  or  replace  the  duties 
of  the  stomach  and  smaller  intestine  in  the  absorption  of  nutriment,  by 
the  regular  employment  of  nutritious  enemata.  When  we  have  to  deal 
with  a  case  of  inflammation,  circumscribed  in  the  situation  of  the  caecum, 
it  need  scarcely  be  said  that  leeching,  poulticing,  fomentation,  and  other 
local  remedial  measures  will  naturally  be  called  into  requisition;  and  that, 
so  soon  as  there  are  clear  indications  of  the  presence  of  pus,  an  opening 
should  be  made  for  its  evacuation;  and  that  the  abscess  having  been  once 
opened  should  if  possible  be  kept  open,  until  we  have  evidence  that  its 
deeper  parts  or  ramifications  have  become  healed.  In  cases  of  this  kind 
also  the  use  of  opium,  though  not  so  universally  imperative  as  where  tliero 
is  peritonitis,  is  generally  desirable  if  not  indispensable;  and  in  them  also, 
purgatives,  though  not  perhaps  to  be  absolutely  prohibited,  should  be 
employed  exceptionally  only,  and  with  the  greatest  caution, — indeed  there 
can  be  little  doubt  that  if  constipation  be  sufficiently  obstinate  to  call  for 
medical  relief,  relief  will  be  afforded  best,  and  by  far  most  safely,  by  the 
use  of  enemata.  Lastly,  in  these  cases,  as  in  all  cases  where  there  is 
abundant  and  long-continued  suppuration  and  hectic,  it  is  of  paramount 
importance  that  the  patient  should  be  sustained  by  abundance  of  nutri- 
tious food,  that  he  should  have  habitually  a  fair  proportion  of  stimulus, 
and  that  the  use  of  tonic  medicines,  especially  vegetable  bitters,  and  tonic 
treatment  generally,  should  be  systematically  enforced. 


COLIC. 

By  J.  Waebubton  Begbie,  M.D.,  F.R.C.P.E. 


The  term  Colic  is  derived  from  the  Greek  KwXov,  the  colon,  or  large 
intestine. 

Defixition. — The  essential  character  of  Colic,  as  ordinarily  under- 
stood, is  severe  pain  in  the  abdomen  (in  a  restricted  view,  in  the  colon), 
augmenting  for  a  time  in  severity,  and  then  gradually  subsiding;  occur- 
ring in  paroxysms,  not  stationary,  but,  on  the  contrary,  moving  from  place 
to  place,  accompanied  by  a  sense  of  constriction  and  tearing,  for  the  most 
part  also  by  that  of  expulsion. 

The  term  Colic  is  now  used  in  nearly  the  same  way  as  the  ancient 
writers  employed  that  of  KwXikos.  It  is,  however,  abundantly  evident 
that  the  disease  described  under  that  name,  by  Aretieus,  for  example,  was 
of  a  much  more  serious  nature  than  ordinary  colic ;  it  was  indeed  a  fre- 
quently fatal  disorder.  In  treating  of  Colics,  liepl  KwXlkwv,  the  learned 
Cappadocian  physician  remarks :  KoXi/coi  S-q  KxetVovrai  ciXou  koL  crrpo^jnD  6^i(ii<i. 
By  lannaeus,  among  the  early  nosologists,  Colic  is  placed  in  the  class 
"  Dolorosi,"  and  is  thus  defined:  "Intestini  dolor  umbilicalis  cum  tormini- 
bus."  Vogel,  using  a  similar  expression  to  denote  the  class,  explains  the 
disease  as  follows:  "Dolores:  Colica,  dolor  spasticus  intestinorum  cum 
obstipatione,  nausea,  et  vomitu."  Sauvage  more  simply  and  briefly  styles 
Colic  "  Dolor  intestinorum ;  "  and  Cullen,  correctly  assigning  the  disease 
a  position  in  the  class  "  Neuroses  "  of  his  nosological  system,  of  which 
"Spasmi"is  the  third  order,  has  thus  described  it:  "Dolor  abdominis, 
prsecipue  circa  umbilicum  torquens ;  vomitus;  alvus  adstricta."  By  French 
and  German  writers  the  terms  "  Colique  "  and  "  Die  Kolik  "  are  respect- 
ively employed  when  treating  of  this  disease. 

A  vast  variety  of  painful  spasmodic  affections  have  been  described 
under  the  name  of  Colic.  Of  these  it  may  only  be  necessary  to  adduce 
as  illustrations  the  following:  "Colica  Hepatica,"  "Colica  Nephritica," 
"  Colica  Uterina,"  as  applied  to  spasmodic  pain,  sudden  in  its  occurrence, 
and  apparently  affecting  the  liver,  kidneys,  or  uterus.  These  expressions 
are  eminently  faulty,  and  it  is  desirable  that  their  use  should  be  entirely 
abandoned. 

It  is  to  the  consideration  of  the  true  or  simple  Colic,  the  "  Colica  spas- 
modica "  of  not  a  few  writers,  that  the  present  article  will  be  devoted. 
"  Lead  Colic,"  or  "  Colica  Pictonum,"  and  for  which  many  other  syn- 
onyms have  been  employed,  will  be  separately  considered,  while  the  occur- 
rence of  Colic,  or  of  colicky  pains,  as  a  symptom  of  different  abdominal 
affections,  inflammatory  and  otherwise,  will  be  noticed  in  the  descriptions 
of  these  maladies  themselves. 

Symptomatology  of  Colic. — As  has  already  been  stated  in  the  defi- 


74  DISEASES   OF  THE  INTESTINES   AND   PERITONEUM. 

nition  of  Colic,  pain  is  its  essential  and  most  characteristic  feature.  This 
pain  is  seldom  continued  or  uniform  for  any  length  of  time,  but,  on  the 
contrary,  is  marked  by  the  occurrence  of  remissions  or  intermissions,  and 
likewise  by  exacerbations,  which  are  frequently  of  very  great,  even  intense 
severity.  So  extreme  is  the  pain  of  Colic  at  times  as  to  cause  persons  of 
heroism  to  utter  loud  groans  and  cries.  While  the  whole  abdomen  or  any 
part  of  it  may  be  the  seat  of  suffering,  the  peculiar  twisting  pain  is  spe- 
cially experienced  in  the  situation  of  the  umbilicus,  as  Cullen  observed: 
**  praecipue  circa  umbilicum  torquens."  '  Great  restlessness  and  frequent 
turning  of  the  body,  changing  from  place  to  place,  distinguish  the  sufferer 
from  Colic.  He  does  not  rest  in  bed,  but  is  prone  to  rise  and  pace  up  and 
down  the  room;  bending  forwards,  he  presses  his  hands  over  the  belly; 
and  when  the  pain  augments  in  severity  is  glad  to  fling  himself  on  his  face 
on  the  bed  or  sofa.  Usually,  while  the  pain  lasts,  the  trunk  is  flexed,  the 
upper  part  bent  forward  over  the  lower.  If  the  patient  be  in  bed  and 
lying  on  the  back,  the  lower  limbs  with  bent  knees  are  often  brought  in 
contact  with  the  abdominal  parietes,  and  are  thus  retained  for  some  time 
by  his  hands.  A  position  of  this  kind  is  meant  when  French  writers,  in 
reference  to  the  sufferer  from  Colic,  use  the  expression,  "le  malade  se 
pelotonne,"  the  patient  rolls  himself  into  a  ball.  By  very  firm  pressure 
over  the  abdomen,  as  by  lying  on  the  belly,  the  pain  is  sometimes  miti- 
gated or  even  for  a  time  removed,  and  this  circumstance  is  of  some  impor- 
tance in  distinguishing  a  spasmodic  from  an  inflammatory  pain,  in  so  far 
as  the  latter  is  invariably  aggravated  by  pressure. 

The  form  of  the  abdomen  is  altered  during  the  continuance  of  Colic. 
There  may  be,  and  this  condition  is  fully  the  more  frequent,  distention, 
with  which  there  is  associated  the  development  of  flatus  on  a  large  scale, 
or  the  parietes  of  the  abdomen  maj^,  on  the  other  hand,  be  retracted.  The 
condition  of  a  distended  colon,  the  seat  of  pain,  may  be  mistaken  for  that 
of  gastric  distention  and  pain.  When  the  former,  however,  occurs,  as  a 
phenomenon  of  the  attack  of  Colic,  there  are  present  also  other  indications 
of  intestinal  suffering,  such  as  irregular  contractions  which  may  frequently 
be  felt  by  the  hand  or  seen,  borborygmi,  and  specially  the  sense  of  bearing 
down  towards,  and  constriction  at,  the  anus.  Besides,  as  Dr.  Wilson  Fox" 
lias  pointed  out,  pain  arising  from  the  large  intestines  is  seldom  felt  so 
much  at  the  ensiform  cartilage  (the  common  seat  of  gastric  uneasiness)  as 
in  the  right  or  left  hypochondriac  regions,  while  there  exists  a  distinct 
difference  between  the  notes  to  be  elicited  on  percussion,  from  the  two  or- 
gans; that  from  a  distended  colon  being  the  less  prolonged,  and  having  a 
higher  pitch. 

Great  general  depression  is  capable  of  being  produced  by  an  attack  of 
Colic.  This  is  seen  in  the  frequently  pale  countenance  of  the  sufferer, 
whose  pulse  also  is  found  to  be  extremely  feeble,  while  the  surface  of  the 
body  is  bedewed  with  a  cold  and  clammy  perspiration.  The  relation  of 
constipation  to  Colic  is  most  important.  A  confined  condition  of  the 
bowels  is  usually,  though  not  invariably  as  some  writers  have  asserted, 
associated  with  Colic;  and  not  unfrequently,  when  the  bowels  have  been 

'  A  recent,  perhaps  the  most  recent,  French  writer  on  Colic  (M.  Martineau),  in  de- 
scribing the  pain,  remarks  :  "La  douleur  est  toute  apeciale.  Les  malades  en  proie  h 
nne  coliqne  eprouvent  une  douleur  vive,  exacerbante.  mobile,  ayant  une  grande  ten- 
dance a  s'irradier.  Elle  se  traduit  par  one  sensation  de  constriction,  de  resserrement, 
de  tortillement,  on  par  nne  sensation  de  dechirure  et  meme  d'expulsion. — Nouveau 
Dictionndire  de  Medecine  et  de  Chirurgie,  pratique,  vol.  viu. 

*  The  Diagnosis  and  Treatment  of  the  Varieties  of  Dyspepsia,  p.  53. 


COLIC.  75 

efficiently  acted  on  by  medicine,  the  pain,  which  may  have  been  of  the 
severest  type,  entirely  disappears.  Neither  is  this  latter  however,  the 
constant  result,  for,  notwithstanding  the  operation  of  laxative  and  cathar- 
tic remedies,  the  pain  in  some  instances  proves  persistent.  Such  cases  are 
infinitely  less  alarming  than  those  in  which  obstruction  of  the  bowels  con- 
tinues, while  the  abdominal  pain  either  diminishes  or  disappears,  for  in 
these  circumstances  the  occurrence,  sooner  or  later,  of  a  regular  attack  of 
ileus  is  to  be  apprehended;  while  in  the  former  case,  the  free  movement 
of  the  bowels,  although  not  immediately,  and  it  may  be  not  even  speedily, 
bringing  relief  to  suffering,  is  surely  succeeded  by  such  before  any  length- 
ened period  has  passed.  In  some  instances  of  Colic,  a  confined  condition 
of  the  bowels  is  really  the  cause  of  the  attack  of  painful  spasm,  while  in 
others  the  constipation  is  the  effect  of  the  spasm.  In  the  more  protracted 
cases  of  Colic,  a  general  febrile  state  is  liable  to  be  induced.  Vomiting 
may  accompany  Colic,  but  is  by  no  means  a  constant  or  characteristic 
symptom  of  this  disorder.  Much  importance  is  to  be  attached  to  the 
pulse  in  Colic,  for  by  its  condition  we  are  not  unfrequently  able  to  distin- 
guish between  a  simple,  although  severe  spasmodic  affection,  and  an  in- 
flammatory disorder.  It  is  to  be  remembered  moreover,  that  in  some  cir- 
cumstances the  latter  is  not  unapt  to  supervene  upon  the  former.  Now, 
in  Colic,  while  the  suffering  is  even  intense,  the  pulse  may  be  little  if  at 
all  altered.  Assuredly  it  is  by  no  means  uncommon  to  find  the  pulse 
under  such  circumstances  remaining  tranquil,  and  in  fact  altogether  nor- 
mal. Smallness  of  the  pulse,  associated  with  marked  depression  of  the 
circulation  generally,  hardness  and  irregularity,  are,  on  the  other  hand,  of 
sufficiently  frequent  occurrence  in  cases  of  Colic'  The  respiration  is  hur- 
ried, and  frequently  unequal.  The  voice  is  apt  to  be  affected  in  cases  of 
marked  severity;  it  becomes  hoarse,  while  at  times  it  is  so  enfeebled  as  to 
be  almost  obliterated.  The  accession  of  Colic  is  by  no  means  uniform  or 
exact.  The  disease  may  be  established  suddenly,  even  abruptly,  and  with- 
out any  apparent  cause,  or  it  may  come  on  gradually,  succeeding  the  oc- 
currence, for  a  time  longer  or  shorter,  of  abdominal  uneasiness,  and  very 
probably  of  occasional  cramps,  which  are  clearly  traceable  to  some  suffi- 
cient cause.  Not  less  variable  are  the  progress  and  duration  of  the 
malady.  It  may  exist  for  days,  or  last  only  for  hours,  or  even  minutes. 
These  irregularities  are  largely  determined  by  the  precise  causes  of  the 
attacks.  An  irregular  intermittence  is  a  characteristic  feature  of  Colic; 
the  duration  of  the  painful  seizures,  and  of  the  intervals  which  separate 
them,  being  subject  to  great  variety. 

Pathology  or  Colic, — Although  the  relation  of  the  abdominal  pain 
and  spasm  in  Colic  to  nerve  irritation,  is  obscure,  the  following  remarks 
appear  to  be  called  for.  It  has  been  clearly  shown  by  carefully  conducted 
experiments,  and  is  now  admitted,  that  the  pneumogastric  nerves  possess 
an  influence  on  the  movements  of  the  intestinal  canal.  Such  experiments 
as  those  referred  to  have  exhibited  the  contractions  of  the  muscular  coats 
of  the  intestines  under  the  application  of  electrical  irritation  to  the  vagi, 
of  as  rapid  and  violent  a  character  as  those  of  voluntary  muscles,  when 
their  motor  nerves  have  been  subjected  to  a  similar  irritation.  Again, 
when  on  irritating  the  ganglionic  plexuses  surrounding  the  aorta,  by 
means  of  the  rotary  apparatus  (durch  den  rotatorischen  Apparat),  th» 
small  intestines    and  colon,  which  had  been  previously  whoUy  inactive, 

'  In  describing  the  pnlse  of  Colic,  Henoch  remarks,  "  Der  Puis  ist  klein  tmd  hart« 
lioh."     (Klinikder  Unterleiba-Krankheiten.) 


76  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

when  the  current  began  to  operate  were  seized  with  universally  active 
movements,  which  continued  for  a  long  time  after  the  current  was  inter- 
rupted. It  is  of  further  interest  to  note,  that  among  central  portions  of 
the  nervous  system  it  is  the  medulla  oblongata  which,  when  irritated  by 
the  galvanic  current,  excites  in  a  decided  manner  the  movements  of  the 
stomach  and  the  intestinal  canal.  Budge  saw  the  same  result  produced 
in  rabbits,  but  in  a  less  degree,  by  irritation  of  the  cerebellum.  The 
Bpinal  cord  and  cerebrum  possess  no  such  influence.  All  experimenters 
have  described  the  movements  of  the  intestinal  canal  as  distinctly  peri- 
staltic or  vermicular.*  M.  Martineau,  in  his  interesting  article  on  Colic  to 
which  reference  has  been  made,  has  pointed  out  that  while  the  pneumo- 
gastric  nerve  is  more  especially  distributed,  as  is  well  known,  to  the  stom- 
ach and  liver,  a  portion  of  the  right  nerve  passes  to  the  semi-lunar  ganglia 
to  anastomose  with  the  splanchnic  nerves  of  the  great  sympathetic,  and 
thus  to  form  the  solar  plexus.  Galvanization  of  the  solar  plexus  and  of 
the  superior  mesenteric  ganglia  equally  causes  contraction  of  the  small 
intestine  and  more  rarely  of  the  large.  Valentin  has  made  the  very  im- 
portant observation  that  an  irritation  of  the  fifth  nerve,  at  the  base  of  the 
skull,  invariably  gives  rise  to  peristaltic  movements  of  the  small  intestine, 
especially  of  the  duodenum  and  upper  part  of  the  jejunum.  Such  being 
proved  experimentally,  we  can  understand  the  occurrence  of  intestinal 
spasm  or  Colic,  as  the  direct  consequence  of  some  forms  of  cerebral  irrita- 
tion. And  although,  as  Romberg  has  remarked,  little  is  known  respecting 
the  influence  which  is  exerted  by  the  affections  of  the  spinal  cord  and  brain, 
upon  spasms  of  the  bowels,  the  very  potent  operation  of  the  emotions, 
fear  and  fright  especially,  but  in  some  instances  also  joy,  in  increasing 
the  movements  of  the  intestines  is  thoroughly  appreciated. 

Etiology  of  Colic. — Certain  temperaments  appear  to  predispose  to 
the  occurrence  of  Colic.  Of  these  the  nervous  and  lymphatic  are  the 
most  distinguished.  Sedentary  occupations  act  in  the  same  manner. 
The  influence  of  age  and  sex  is  sufficiently  marked  to  be  worthy  of  notice. 
In  youth  and  adult  age.  Colic  is  more  common  than  in  advanced  life,  and 
among  females  it  occurs  more  frequently  than  among  males.  Among  the 
exciting  causes  of  Colic,  one  of  the  most  frequent  is  the  presence  of  some 
indigestible  article  of  food  in  the  bowels.  The  influence  of  cold  in  pro- 
ducing attacks  of  Colic  is  also  remarkable,  and  particularly,  it  has  been 
noticed,  cold  applied  to  the  feet.  There  are  some  individuals  who  are 
certain  to  suffer  from  an  attack  of  Colic,  if  by  any  means  their  feet  have 
become  cold.  The  association  of  biliary  derangement  with  tlie  occurrence 
of  intestinal  spasm  is  not  uncommon,  and  this  particular  form  of  the  dis- 
ease has  been  designated  "  Bilious  Colic."  Its  distinctive  features  are  the 
vomiting  of  biliary  matters,  and  the  presence  of  a  more  or  less  icteric  tint 
of  the  conjunctivae  and  surface  of  the  body.  Lastly,  under  this  head,  it 
is  to  be  held  in  remembrance  that  in  some  instances  the  existence  of  a 
gouty  or  rheumatic  habit  of  body  plays  a  decided  part  in  the  origination 
of  attacks  of  Colic,  although  it  may  probably  be  admitted  that  such  con- 
stitutional disorders  are  still  more  potent  in  determining  the  true  enter- 
dlgia  or  neuralgia  of  the  bowels,  a  disease  which  is  to  be  distinguished 
from  Colic. 

Treatment  op  Colic. — To  relieve  pain,  and  generally  speaking  to  act 
on  the  confined  bowels,  are  the  chief  indications  for  treatment  in  Colic. 
In  the  milder  instances  of  the  disease,  unaccompanied  by  any  notable  de- 

1  Romberg,  Lebrbuch  der  Nervenkrankbeiten  des  Menscben  ;  Darmkrampf. 


COLIC.  <  7 

rangement  of  the  "  primae  viae,"  this  can  usually  be  accomplished  by  the 
external  application  of  "warmth,  or  of  rubefacients,  such  as  mustard  and 
turpentine,  and  by  the  administration  of  a  little  stimulant,  or  carminative 
mixture.  A  small  quantity  of  brandy  with  hot  water,  a  teaspoonful  of 
the  compound  tincture  of  cardamoms  in  warm  water,  or  twenty  drops  of 
the  compound  tincture  of  chloroform,  will  be  found  very  serviceable  for 
this  purpose.  Preparations  of  peppermint,  ginger,  and  cloves  may  also 
be  similarly  employed.  In  more  severe  cases  of  Colic,  or  in  instances 
where  the  remedies  already  mentioned  have  failed  to  relieve  the  pain,  it 
will  be  necessary  to  administer  anodyne  medicines,  and  as  early  as  possi- 
ble to  evacuate  the  bowels.  The  preparations  of  opium  are  most  useful 
among  the  former;  the  compound  tincture  of  camphor  or  English  pare- 
goric— in  doses  of  thirty  to  sixty  minims — or  a  full  dose  of  laudanum. 
With  these  a  dose  of  castor-oil,  or  compound  rhubarb  powder  (Gregory's 
mixture),  should  be  given,  and  repeated  after  a  short  interval  if  relief  to 
pain  and  solution  of  the  bowels  be  not  obtained, 

A  tablespoonful  of  castor-oil  with  twenty-five  drops  of  laudanum  in 
peppermint  water,  or  two  teaspoonfuls  of  Gregory's  mixture  with  a  tea- 
spoonful  of  compound  tincture  of  camphor,  and  a  similar  quantity  of 
aromatic  spirit  of  ammonia  in  a  small  wineglassful  of  cinnamon  water,  will 
be  found  most  available  prescriptions  in  such  cases. 

When  the  attack  of  Colic  has  speedily  succeeded  the  taking  of  some 
indigestible  article  of  food,  it  may  be  advisable  to  produce  vomiting  by 
the  administration  of  an  emetic  of  ipecacuanha  wine,  or  by  draughts  of 
hot  water. 

Should  the  bowels  not  respond  to  the  mild  remedies  already  mentioned, 
it  will  be  necessary  to  have  recourse  to  the  use  of  stronger  cathartics. 
Of  these,  sulphate  of  magnesia,  particularly  with  the  addition  of  a  little 
sulphuric  acid,  as  Henry's  salts,  and  senna,  also  the  compound  jalap  pow- 
der and  calomel,  may  be  regarded  as  the  chief. 

The  employment  of  laxative  enemata  should  also  be  had  recourse  to. 
A  large  injection  of  warm  water  will  frequently  be  found  most  useful  in 
relieving  the  pain,  and  in  effectually  acting  on  the  bowels  in  cases  of 
Colic. 

The  prophylactic  treatment  of  Colic  consists  in  a  careful  regulation  of 
diet,  particularly  in  the  avoidance  of  all  indigestible  articles  of  food,  and 
in  the  protection  of  the  surface  of  the  body  from  the  injurious  influence 
of  cold.  Wearing  flannel  over  the  abdomen,  and  the  warm  covering  of 
the  feet,  are  especially  to  be  enjoined. 


COLITIS. 

By  J.  Waebueton  Begbie,  M.D.,  F.R.C.P.E. 


There  seems  to  be  some  ground,  at  all  events  for  supposing  that  the 
large  intestine  may  be  the  seat  of  inflammatory  action,  differing  in  essen- 
tial particulars  from  the  dysenteric  process  which  will  be  immediately 
described.  To  indicate  the  simple  inflammation  of  the  colon,  as  distiji- 
guished  from  dysentery,  the  term  Colitis  has  been  employed,  Colonitis 
has  been  used  in  the  same  sense.  The  French  have  the  word  Colite,  and 
the  Germans  the  expression  Entzundunrj  des  Schleimhautes  des  Kolons. 

In  dysentery  the  mucous  membrane  of  the  rectum  and  colon  is  prima- 
rily involved  while  the  pathological  changes  which  are  so  eminently  char- 
acteristic of  the  disease  are  wrought  in  it.  In  Colitis,  on  the  other  hand, 
there  is  in  all  probability  a  commencement  of  inflammation  in  the  sub- 
mucous or  connective  tissue,  which  underlies  the  mucous  membrane,  the 
glandular  structures  of  the  latter  being  in  the  first  instance  uninvolved. 
The  result,  however,  is  a  diffuse  gangrenous  inflammation  of  the  mucous 
membrane;  and  when  this  has  occurred,  there  is  no  possibility  of  distin- 
guishing the  ulceration  thus  formed  from  that  which  has  resulted  from  the 
dysenteric  process. 

It  is,  however,  to  be  borne  in  mind  that  the  most  experienced  physi- 
cians and  ablest  writers  have  differed  in  respect  to  the  essential  pathology 
and  the  characteristic  morbid  appearances  in  dysentery.  The  necessary  ex- 
istence of  ulceration  has,  for  example,  been  denied  by  some,  and  the  special 
participation  of  the  glandular  structures  of  the  colon,  so  commonly  con- 
ceived to  hold  true  of  dysentery,  has  been  equally  opposed  by  others.  In 
these  circumstances  it  must  be  admitted  that  great  difficulty  at  present 
exists  in  the  way  of  correctly  distinguishing  between  the  different  forms 
— if  there  really  be  different  forms — of  inflammatory  disease  affecting  the 
colon,  and  renewed  investigation  with  careful  examination  of  the  various 
structures  and  tissues  entering  into  the  anatomy  of  that  portion  of  the 
intestine,  is  required  before  any  satisfactory  conclusions  on  the  subject 
can  be  arrived  at. 


DIARRHCEA. 

By   S.   O.   Habeeshon,   M.D. 


DiARRHCEA  consists  in  the  abnormal  frequency  of  evacuation  of  the 
bowels,  as  defined  by  Cullen,  "  Dejectio  frequens;  morbus  non  contagiosa; 
pyrexia  nulla  primaria: "  and  it  arises  generally,  but  not  exclusively,  from 
an  irritated  condition  of  the  large  intestine. 

It  manifests  itself  in  various  forms,  some  of  which  have  received  dis- 
tinctive appellations,  as  Diarrhoea  crapulosa,  billosa,  mucosa  or  catarrh- 
alis,  dysenterica,  and  choleraica,  to  which  might  be  added  nervosa,  and 
coUiquativa. 

Diarrhoea  crapulosa  is  that  state  in  which  there  is  an  unnatural  fluid- 
ity and  excess  of  fascal  excretion,  in  which  the  evacuations  are  healthy  in 
character,  but  in  excessive  frequency  and  fluidity;  in  some  cases  very 
large  quantities  are  discharged  without  any  discomfort,  but,  on  the  con- 
trary, with  relief  to  the  patient.  This  form  of  diarrhoea  should  not  be 
checked  when  it  is  a  natural  discharge;  but  more  frequently  it  is  the  se- 
quence of  irritating  and  undigested  food.  Too  great  a  quantity  may  have 
been  taken,  and  a  portion  of  it  may  have  passed  into  the  intestine  crude 
and  partially  dissolved;  or  from  its  insoluble  character  portions  of  the 
food,  as  the  woody  fibre  of  vegetables  and  fruit,  may  have  remained  un- 
changed by  the  gastric  juice,  and  irritate  the  intestine.  Again,  active 
mental  or  bodily  exercise  immediately  after  a  meal,  which  has  been  suit- 
able both  as  to  quality  and  quantity,  may  interfere  with  the  proper  so- 
lution of  food,  and  lead  to  its  hasty  passage  into  the  duodenum. 

When  the  alimentary  canal  becomes  in  this  way  loaded  with  undissol- 
ved ingesta,  pain  of  a  griping  and  twisting  character  ensues,  from  irreg- 
ular peristaltic  action  and  from  distention.  The  abdomen  becomes  full; 
the  skin  and  complexion  sallow;  the  tongue  is  furred;  the  pulse  is  com- 
pressible; headache  and  giddiness  are  often  present;  the  sleep  is  disturb- 
ed; the  bowels  act  frequently  and  irregularly,  and  the  motions  contain 
undigested  substances,  ^vith  fluid  faeces  or  with  firm  scybala.  Considerable 
soreness  is  at  times  experienced  in  the  course  of  the  large  intestine,  and 
distressing  tenesmus  arises  from  the  irritation  of  the  mucous  membrane 
of  the  rectum. 

The  term  lientery  is  used  to  designate  the  condition  in  which  the  food 
is  passed  almost  unacted  upon,  either  by  the  gastric  or  intestinal  secre- 
tions, and  in  a  very  short  time  after  having  been  taken.  This  state  arises 
from  excessive  irritability  of  the  whole  intestinal  tract,  with  disordered 
secretions;  it  is  not  unfrequent  in  children  after  protracted  diarrhoea,  and 
gastro-enteritis.  It  is  of  common  occurrence  among  the  out-patients  of 
large  hospitals;  and  in  not  a  few  cases  leads  to  a  fatal  termination. 

Jiilious  Diarrhoea  is  also  a  form  of  disease  produced  by  the  effusioa 
6 


82  DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

of  irritating  substances  into  the  intestine;  not,  however,  from  without, 
but  from  the  liver,  and  possibly  from  the  pancreas  and  follicular  glands. 

The  secretion  of  the  liver  becomes  either  excessive  in  quantity,  or  ir- 
ritating in  quality;  and  the  contents  of  the  canal  are  apparently  hurried 
onward,  and  evacuated  as  frequent  loose  and  bilious  dejections.  The 
causes  of  this  state  are  various,  and  sometimes  the  disorder  of  the  liver  is 
really  secondary  to  an  irritable  condition  of  the  intestine  itself,  due  to 
excess,  especially  of  stimulants.  Exposure  to  cold  and  wet  induces  dis- 
eases of  this  kind,  especially  in  the  autumnal  season  of  the  year.  The 
symptoms  are  somewhat  similar  to  those  previously  mentioned;  the  pain 
is  slight,  unless  the  disease  becomes  aggravated;  the  tongue  is  furred; 
the  complexion  is  sallow;  some  febrile  excitement  is  present  with  frontal 
headache;  pain  in  the  abdomen  and  in  the  hypochondriac  region.  This 
form  of  diarrhoea  is  sometimes  epidemic,  attacking  considerable  numbers 
exposed  to  similar  exciting  causes;  and  when  severe,  and  accompanied 
with  colic  or  spasmodic  pain  in  the  abdomen  and  legs,  and  especially  with 
vomiting,  it  constitutes  English  cholera,  and  often  leads  to  great  pros- 
tration of  strength.  The  countenance  becomes  haggard,  the  eyes  appear 
sunken,  the  pulse  is  exceedingly  compressible  and  failing,  the  temperature 
below  normal,  the  tongue  is  brown,  and  the  patient  too  frequently  sinks 
exhausted,  especially  if  very  young,  or  advanced  in  life,  or  if  already 
prostrate  from  other  disease. 

Abnormal  conditions  of  the  bile  tend  to  produce  other  modifications; 
thus,  the  motions  in  diarrhoea  are  sometimes  in  a  state  of  fermentation ; 
they  are  watery,  frothy,  and  only  contain  fluid  faecal  matter.  This  I  have 
seen  very  prominently  in  a  case  of  phthisis,  in  which  there  was  probably 
some  ulceration  of  the  intestine,  when  the  evacuations  consisted  of  long 
shreds  of  mucus,  and  casts  composed  of  columnar  epithelium  and  nuclei. 
After  a  few  weeks  this  condition  subsided  under  the  use  of  cusparia,  sul- 
phuric acid,  and  opium,  with  occasional  starch  injections,  but  it  was  fol- 
lowed by  very  severe  pain  in  the  course  of  the  colon,  and  by  frothy, 
yeast-like  evacuations.  For  this  state  I  used  injections  of  charcoal,'  3  ij. 
to  about  a  pint  of  thin  barley-water,  with  great  relief;  the  character  of 
the  evacuations  improved,  and  in  a  short  time  became  naturally  faecal,  the 
pain  diminished,  and  the  strength  increased.  I  afterwards  gave  the  pa- 
tient several  grains  of  myrrh,  twice  or  three  times  a  day,  with  manifest 
improvement,  till  she  left  the  hospital  several  months  later. 

Diarrhoea  sometimes  occurs  with  an  absence  of  bile  in  the  evacuations; 
in  jaundice  this  may  be  the  case;  it  is  so  in  cholera;  and  towards  the  close 
of  chronic  disease  the  liver  may  cease  to  pour  out  its  ordinary  secretion. 
I  have  seen  it  in  a  patient  slowly  sinking  from  the  exhaustion  consequent 
on  diabetes,  without  phthisis.  The  motions  were  in  that  case  often  quite 
white,  like  water  frothy  from  an  abundance  of  soap. 

There  is,  also,  a  form  of  diarrhoea  arising  from  the  inhalation  of  nox- 
ious effluvia,  which  is  closely  allied  to  that  just  described;  the  fumes  of 
sulphuretted  hydrogen  gas  are  absorbed  by  the  lungs,  and  through  their 
minute  capillaries  enter  the  blood;  the  gas  is  circulated  and  acts  as  a 
poisonous  agent  on  that  vital  fluid,  and  if  concentrated,  proves  rapidly 
fatal;  if  less  concentrated,  it  produces  headache,  and  frequently  also 
diarrhoea.  It  appears,  that  not  only  are  the  secretions  of  the  liver  and 
alimentary  canal  changed,  but  that,  by  means  of  this  excessive  action  of 
the  abdominal  viscera,  the  poison  is  eliminated  from  the  system.     So  rapid 

'  See  Dr.  Thcophilus  Thompson's  Lectures  on  Phthisis. 


DIAERH(EA.  83 

is  this  agent  in  its  action,  that  to  be  present  for  a  short  time,  even  a 
quarter  of  an  hour,  in  a  dissecting-room,  will,  in  some  persons,  produce 
distressing  diarrhoea. 

In  typhoid  fever,  and  in  phthisis,  ulceration  of  the  small  intestine  is 
frequently  found  to  be  accompanied  with  diarrhcea;  of  these  we  have 
spoken  elsewhere;  in  some  of  these  cases  the  large  intestine  is  involved, 
but  in  others,  when  the  diarrhoea  has  been  severe,  such  has  not  been  the 
case.  It  would  appear  that  the  continuity  of  structure  with  the  ulcerated 
ileum,  the  irritating  excreta,  as  well  as  the  changed  and  probably  acceler- 
ated peristaltic  action  of  the  small  intestine,  tend  to  excite  over-action  of 
the  colon,  and  thus  to  set  up  diarrhcea. 

Catarrhal  and  mucous  diarrhoea  arise  from  a  state  of  slight  inflamma- 
tory disease,  closely  allied  to  ordinary  coryza,  affecting  the  mucous  mem- 
brane of  the  large  intestine.  The  secretion  is  at  first  checked,  but  after- 
wards greatly  increased,  and  a  watery  feculent  mucus  is  discharged  mixed 
with  the  ordinary  faeces.  This  state  may  continue  for  several  days,  or 
even  for  a  much  longer  period:  the  motions  are  loose,  and  somewhat 
watery;  and  if  the  rectum  be  affected,  considerable  tenesmus  is  produced; 
the  pain  and  febrile  excitement  are  slight,  but  the  strength  of  the  patient 
is  reduced,  and  he  is  unequal  to  his  usual  duties;  the  tongue  is  clean, 
the  pulse  is  compressible;  the  bladder  sometimes  sympathizes  with  this 
irritation,  and  a  frequent  desire  to  pass  urine  is  induced;  in  little  girls, 
also,  a  muco-purulent  secretion  often  takes  place  from  the  vulva;  redness 
of  the  parts  is  produced  with  smarting  pain,  and  the  idea  has  sometimes 
been  suggested  that  the  child  has  been  cruelly  treated. 

In  this  form  of  diarrhoea  the  evacuations  contain  a  considerable  quan- 
tity of  mucus,  and  a  little  blood  is  often  observed;  these  are  especially 
present  when  irritation  occurs  very  low  down  in  the  rectum,  or  is  set  up 
by  haemorrhoids;  and  the  mucus  will  sometimes  pass  both  before  and  after 
the  dejection. 

In  infants  the  disease  closely  resembles  gastro-enteritis,  or  it  is,  per- 
haps, rather  identical  with  it,  but  differing  in  degree,  as  a  greater  or  less 
part  of  the  alimentary  canal  is  affected;  in  these  cases  the  whole  tract 
sometimes  becomes  rapidly  involved,  and  great,  if  not  fatal  prostration, 
rapidly  ensues.     (See  Muco-Enteritis.) 

As  with  bilious  diarrhoea,  before  mentioned,  it  is  in  very  young  or 
aged  subjects  that  catarrhal  diarrhoea,  or  catarrhal  inflammation  of  the 
large  intestine,  leads  to  more  serious  disease,  but  it  is  also  found  among 
those  in  whom  chronic  or  more  exhausting  disease  has  existed. 

This  catarrhal  diarrhoea  not  unfrequently  becomes  a  chronic  disease, 
the  more  severe  symptoms  cease,  but  still  the  bowels  do  not  act  in  their 
normal  manner;  constipation  often  ensues,  and  afterwards  a  fresh  loose- 
ness of  the  bowels,  and  this  alternation  is  oftentimes  repeated,  or  the  more 
solid  motions  are  followed  by  a  discharge  of  mucus  coating  the  faeces; 
sometimes  the  mucus  is  passed  in  considerable  quantity  after  the  evacua- 
tion, or  it  forms  an  elongated  flake  or  cast  of  the  intestine.  I  have  ob- 
served this  condition  following  severe  disease  of  the  intestines  of  a  dysen- 
teric character,  and  it  is  sometimes  associated  with  a  state  of  chronic  con- 
gestion of  the  liver;  again,  it  is  often  perpetuated  by  the  presence  of 
haemorrhoids,  and  by  ovarian  disease.  It  may  exist  for  many  years  with- 
out causing  much  derangement  of  health. 

Morbid  anatomy. — Many  instances  have  been  known  of  fatal  diarrhoea 

'in  which  the  appearance  of  the  mucous  membrane  has  been  normal,  its 

congestion  has  entirely  disappeared,  and  a  thin. mucus  only  has  been 


84  DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

found  upon  the  membrane.  But  this  is  not  always  the  case,  and  there 
are  several  recognized  pathological  changes  which  are  frequently  present. 
First  of  these,  because  most  frequent  and  therefore  the  more  important, 
is  a  vivid  injection  in  more  or  less  isolated  patches. 

2dly.  When  the  diarrhoea  has  been  chronic,  the  mucous  membrane  is 
not  unfrequently  covered  by  a  thick  layer  of  mucus,  and  presents  a  gray 
color.  I  have  frequently  examined  membranes  thus  changed  (as  before 
described;  see  Duodenum  and  Caecum),  and  have  observed  that  the  color 
arises  from  minute  particles  of  dark  pigmental  matter  deposited  in  the 
substance  of  the  mucous  membrane.  Prolonged  congestion  is  known  to 
give  rise  to  similar  pigmentary  changes  in  many  parts,  as  in  the  skin,  liver, 
lung,  heart,  &c.,  and  wherever  this  pigmentary  deposit  occurs  it  is  found 
to  be  due,  as  I  have  described  here,  to  grains  of  varying  tint — orange, 
red,  brown,  or  black.  One  must  regard  these  grains  as  the  remnants  of 
actually  extravasated  blood  or  to  the  arrest  of  some  of  the  oxidizing  or 
other  processes  which  the  blood  coloring  matter  probably  undergoes  in 
its  passage  through  the  various  tissues. 

In  the  large  intestine  this  pigmental  deposit  is  found  in  minute  circles 
around  the  follicles. 

3dly.  The  mucous  membrane,  and  also  the  connecting  cellular  tissue, 
become  thickened. 

4thly.  Minute  ulceration,  probably  follicular,  is  found  extending  through 
more  or  less  of  the  length  of  the  colon.  These  ulcerations  are  about  one- 
sixteenth  of  an  inch  in  diameter,  and  present  a  minute  black  zone  around 
each  of  them.  This  state  would  be  regarded  by  many  as  the  result  of 
dysentery. 

Dysenteric  Diarrhoea. — Purging  is  the  most  marked  symptom  of  dys- 
entery, and  the  lesser  degrees  of  irritation  which  we  have  considered 
under  the  term  of  catarrhal  diarrhoea  might  be  regarded  as  a  form  of  dys- 
entery of  the  mildest  character.  In  dysentery,  however,  the  diseased 
mucous  membrane  rapidly  passes  into  a  state  of  ulceration,  and  blood  is 
discharged  with  the  faecal  excreta. 

In  Choleraic  Diarrhoea  a  thin,  very  abundant  watery  mucus  is  dis- 
charged from  the  alimentary  canal.  The  evacuation  may  have  very  little 
color,  and  present  the  appearance  of  rice-water.  It  is  often  alkaline  in 
character,  and  consists  of  nuclei  and  epithelial  cells  in  various  degrees  of 
development.  After  death  the  membrane  is  found  to  be  entire,  and  pale 
or  sodden;  the  solitary  and  Peyer's  glands  are  enlarged.  In  many  cases  of 
uncomplicated  cholera  which  I  have  examined,  no  further  morbid  appear- 
ance was  presented. 

Of  late  years  a  belief  in  a  fungous  growth  has  been  revived,  and  the 
dejections  of  cholera  have  been  said  by  Hallier  and  others  to  contain  spe- 
cific spores.  Some  very  careful  and  prolonged  observations,  however,  by 
Drs.  Lewis  and  Cunningham,  in  India,  controvert  this  opinion. 

The  symptoms  are  those  of  rapid  prostration,  with  pallor  and  sunken 
eye;  the  pulse  is  compressible,  the  tongue  is  cool,  and  the  voice  is  often 
scarcely  audible;  the  abdomen  is  collapsed,  and  the  urine  is  scanty  in 
quantity;  the  stomach  is  often  exceedingly  irritable,  so  that  everything  is 
at  once  rejected  from  it;  the  alvine  evacuations  are  generally  frequent, 
and  of  the  character  before  mentioned;  and  severe  cramps  in  the  legs  and 
in  the  abdomen  are  often  present.  This  state  may  pass  into  one  of  pro- 
found collapse,  even  after  one  evacuation  of  the  character  of  rice-water. 


DIARRIKEA.  85 

but  as  the  prostration  subsides,  in  favorable  cases,  I  have  never  observed" 
the  febrile  excitement  which  is  secondary  to  true  cholera. 

Another  kind  of  diarrhoea  is  that  which  has  been  correctly  called 
Serous,  and  which  is  frequently  observed  in  albuminuria,  A  dropsical 
condition  of  the  mucous  membrane  is  induced,  and  the  serous  exudation 
from  the  overcharged  capillaries  leads  to  watery  discharge  into  the  colon, 
and  thus  to  diarrhoea.  This  state  of  the  mucous  membrane  is  precisely 
analogous  to  the  cedema  of  the  lungs,  and  to  anasarca  of  the  cellular  tissue 
ill  renal  disease.  So  frequently  is  diarrhoea  present  in  these  cases,  that 
it  may  almost  be  regarded  as  a  symptom  of  the  disease,  and  when  mode- 
rate is  beneficial  in  its  results.  It  is  the  action  we  often  seek  to  produce 
artificially  by  powerful  hydragogue  cathartics,  so  as  to  diminish  the  quan- 
tity of  urea  circulating  in  the  blood,  and  to  relieve  the  oppressed  kidney. 
All  these  fluid  evacuations  contain  urea,  as  does  the  gastric  juice  and  the 
mucus  discharged  from  the  lungs. 

Another  class  of  cases  which  can  scarcely  be  placed  among  those  pre- 
viously mentioned,  arise  from  fright,  from  excessive  mental  agitation, 
from  want  of  food,  and  from  exhausting  disease;  the  former  cases  are  of 
mental  origin,  the  latter  constitute  what  is  sometimes  called  "  colliquative 
diarrhoea; "  and  the  condition  of  the  mucous  membrane  corresponds  to 
that  of  the  skin,  from  which  profuse  partial  sweats  break  out. 

In  fright  the  capillaries  of  the  face  become  blanched,  and  the  blood 
leaves  the  whole  of  the  surface;  the  cavities  of  the  heart  are  increasingly 
distended,  hence  the  discomfort  there  experienced,  and  the  mucous  mem- 
brane of  the  intestine  is  probably  also  engorged;  therefore  the  discharge 
from  the  mucous  membrane  is  to  a  certain  extent  beneficial  in  relieving 
internal  congestion.  The  intimate  connection  of  the  sympathetic  nerve 
with  the  centres  of  thought  and  feeling  is  the  probable  explanation  of 
these  instances  of  diarrhoea  following  mental  agitation. 

In  scurvy,  purpura,  starvation,  &c.,  the  altered  character  of  the  blood 
leads  to  the  effusion  of  serum,  or  blood,  into  the  mucous  membrane,  or 
into  the  canal  itself,  corresponding  to  the  effusion  into  the  skin.  In  some 
fatal  cases  of  purpura  the  whole  of  the  mucous  membrane  of  the  alimen- 
tary canal  is  studded  with  spots  of  ecchymosis.  An  interesting  case  of 
this  kind  occurred  at  Guy's  Hospital  in  1856,  in  a  young  man  who  had 
been  starved  to  death. 

Discharge  of  blood,  or  melce?ia. — Obstruction  of  the  portal  circulation, 
either  from  pulmonary,  from  cardiac,  or  from  hepatic  disease,  leads  to 
great  engorgement  of  the  mucous  membrane  of  the  whole  alimentary 
canal;  and  this  congestion  may  cause  haemorrhage  from  the  bowels.  In 
examining  the  mucous  membrane  in  these  cases,  it  is  very  common  to  find 
points  of  ecchymosis,  and  the  capillary  vessels  of  the  membrane  much  dis- 
tended. Under  a  low  magnifying  power  we  find  the  capillaries  beauti- 
fully injected,  with  extravasated  blood  between  them,  still,  however,  re- 
strained by  the  unbroken  epithelial  surface  and  its  basement  membrane; 
if  the  rupture  of  this  membrane  occur  blood  is  extravasated.  The  dis- 
charge of  blood  may  be  a  symptom  of  various  diseases;  thus,  ulceration 
is  a  frequent  cause  of  hfemorrhage  from  the  bowels,  and  the  ulcer  may  be 
located  in  any  part  of  the  canal;  in  the  stomach  and  duodenum  from  va- 
rious causes;  in  the  small  intestine  in  fever  and  in  phthisis;  in  the  colon 
in  dysentery,  &c. 

The  blood  does  not  always  present  the  same  appearance;  if  it  arise 
from  hiiemorrhoidal  vessels  the  blood  will  be  florid,  and  precede  or  follow 
the  dejection;  if  it  come  from  some  higher  part  of  the  canal  it  is  incor- 


86  DISEASES   OF  THE   INTESTIITES   AND   PERITONEUM. 

porated  with  the  faeces;  and  when  it  has  traversed  a  considerable  portion 
of  the  canal,  it  becomes  altered  by  admixture  with  the  secretions  from  the 
mucous  membrane.  This  is  the  case,  to  some  extent,  when  the  blood  is 
poured  into  the  caecum,  but  is  especially  so  whenever  it  has  been  extrava- 
sated  into  the  stomach ;  the  acids  of  the  gastric  juice  act  upon  the  ef- 
fused blood,  so  that  it  becomes  black,  and  when  discharged  from  the  in- 
testine it  resembles  a  pitchy  fluid,  constituting  true  melaena. 

The  symptoins  of  diarrhoea  have,  perhaps,  been  sufficiently  described 
in  mentioning  its  several  forms  ;  and  they  vary  according  to  the  cause. 
In  the  simplest  form  there  is  neither  pain  nor  constitutional  disturbance  ; 
in  more  aggravated  cases  there  may  be  severe  colic,  and  febrile  excite- 
ment; and  generally,  unless  there  be  hepatic  disturbance  and  derangement 
of  the  whole  mucous  tract,  the  tongue  is  clean,  it  is  then  furred  and  in- 
jected, and  in  typhoid  prostration  assumes  a  brownish  color.  The  pulse 
is  compressible,  and  the  consequent  prostration  is  often  very  alarming, 
especially  in  infants  and  aged  persons,  and  in  some  cases  it  leads  to  a 
fatal  result. 

It  is  important  carefully  to  mark  the  character  of  the  evacuations; 
first,  as  to  the  admixture  of  undigested  substances;  secondly,  as  to  the 
fluidity  of  the  evacuations  ;  a  simple  fluid  state,  with  normal  excreta,  in- 
dicates irritation  of  the  mucous  membrane  in  a  slight  degree;  thirdly,  the 
jyresence  of  mucus  is  evidence  of  more  severe  irritation  of  the  colon;  this 
is  sometimes  found  in  excessive  quantity,  and  is  easily  recognized  by 
pouring  the  evacuation  from  one  vessel  into  another;  fourthly,  if  more 
acute  disease  of  the  colon  exist,  detached  portions  of  faeces  are  found 
floating  on  the  fluid,  which  from  the  rapidity  of  its  discharge,  and  possibly 
also  from  intestinal  changes,  is  often  frothy,  from  the  admixture  of  air; 
fifthly,  in  severe  diarrhcea,  thin  watery  fluid  may  be  discharged  with 
scybala,  and  with  sedimentary  portions  of  faecal  matter  ;  *  sixthly,  thin 
fluid,  almost  like  clear  water,  may  be  passed,  as  in  some  cases  of  albumi- 
nuria, from  an  oedematous  condition  of  the  membrane,  or  like  rice-water 
in  choleraic  diarrhoea,  or  like  soap-suds  when  with  colliquative  diarrhoea 
the  hepatic  secretion  is  also  checked;  seventhly,  the  faeces  are  sometimes 
discharged  in  a  state  indicative  of  fermentative  action,  and  a  frothy  sur- 
face is  produced  of  the  appearance  of  yeast,  and  the  whole  discharge 
closely  resembles  the  matters  occasionally  ejected  from  the  stomach  in 
obstructive  disease  at  the  pylorus;  eighthly,  as  to  the  color  of  the  evacu- 
tion,  we  have  evidence  thereby  of  the  excess  and  of  the  paucity  of  bile, 
sometimes  the  stool  being  of  a  deep  brown  color,  at  others  almost  as  pale 
as  chalk;  ninthly,  the  color  may  be  changed  by  the  admixture  of  such 
substances  as  logwood  administered  medicinally,  or  blackened  by  steel 
medicines,  the  sulphide  of  iron  having  been  formed;  and  tenthly,  the 
color  is  a  guide  to  the  detection  of  blood.  Blood  in  the  alvine  discharges 
may  be  only  observable  by  microscopical  examination;  but  if  in  larger 
quantity,  the  color  varies  from  the  ordinary  appearance  of  blood  to  the 
black  pitchy  stool  of  melaena,  as  we  have  before  mentioned,  according  to 
the  position  of  the  haemorrhage  in  the  canal.  The  green  color  of  the  dis- 
charges in  the  severe  diarrhoea  of  children,  we  believe,  with  Dr.  Golding 
Bird,  to  be  altered  blood  from  an  irritated  and  perhaps  aphthous  surface. 
Again,  in  severe  dysentery,  thin  watery  fluid,  like  the  washing  of  beef, 
is  sometimes  discharged,  consisting  of  blood  with  mucus,  and  of  imperfect 
epithelial  elements.     To  these  dysenteric  evacuations  we  shall  have  again 

*  Dr.  Osborne  "  On  the  Examination  of  the  Faeces,"  •  Dublin  Quart.,'  1853. 


DIAREH(EA.  87 

to  refer.  Lastly,  the  odor  of  the  faeces  is  not  altogether  unimportant; 
sometimes  they  are  tolerably  fetid  from  rapid  degenerative  changes,  at 
other  times  they  have  scarcely  any  odor.  In  many  instances  the  micro- 
scope enables  us  to  detect  an  excess  of  mucus,  the  presence  of  blood,  the 
rapid  discharge  of  epithelial  elements  and  nuclei,  and  other  organic  and 
inorganic  substances,  which  the  unassisted  eye  would  in  vain  search  for. 
We  have  elsewhere  referred  to  the  occasional  presence  of  phosphatio 
crystals  upon  the  mucous  membrane  of  the  intestines,  and  they  are  some- 
times found  in  the  alvine  discharges,  in  simple  as  well  as  in  typhoid 
diarrhoea.  The  presence  of  fatty  matters  in  the  evacuations  was  first 
noticed  by  Dr.  Bright,  in  connection  with  disease  of  the  pancreas;  and 
the  observations  more  recently  made  in  reference  to  the  physiological 
effects  of  the  pancreatic  fluid  have  directed  increased  attention  to  the 
subject.  It  must  not  be  forgotten  that  we  sometimes  find  oleaginous 
substances  discharged  after  the  administration  of  large  quantities  of  milk 
and  of  cod-liver  oil;  thus  in  one  case  masses  of  fat  as  large  as  filberts 
were  sent  to  me  by  a  patient  affected  with  phthisis,  who  had  partaken  of 
milk  very  freely;  still,  the  observation  has  been  confirmed  by  subsequent 
observers,  that  fatty  matters  are  sometimes  discharged  in  the  alvine 
evacuations  in  disease  of  the  pancreas,  and  sometimes  in  extensive  disease 
of  the  mesenteric  glands. 

The  causes  of  diarrhoea  have  been  partially  referred  to. 

(a)  The  most  common  cause  of  ordinary  diarrhoea  is  exposure  to  cold 
and  wet;  standing  in  damp  places;  allowing  the  legs  and  loins  to  become 
damped  and  chilled;  sitting  down  upon  the  ground,  and  falling  asleep  in 
the  open  air;  injudicious  bathing;  the  habit  of  leaving  off  flannel  garments 
in  hot  weather,  by  which  perspiration  more  rapidly  evaporates,  and  the 
blood  is  driven  from  the  surface  towards  the  internal  organs. 

{b)  Improper  and  indigestible  food,  unripe  fruit,  and  an  excess  of  un- 
cooked fruit;  salads,  pastries,  and  much  that  modern  cookery  produces, 
especially  when  an  excess  in  quantity  is  combined  with  an  injurious  quality. 

In  infants  a  fertile  source  of  diarrhoea,  often  passing  into  severe  gastro- 
enteritis, is  the  administration  of  unsuitable  food,  the  injurious  effects  of 
which  are  greatly  increased  by  exposure  to  cold.  In  hospital  and  dispen- 
sary practice  this  cause  of  disease  is  observed  to  a  frightful  extent  ;  at 
seven  or  eight  months,  even  while  the  infant  is,  in  a  great  measure,  nour- 
ished by  the  breast  of  the  mother,  meat,  raw  vegetables,  and  fruits,  sweets, 
almost  ad  Ubitum,  are  given;  and  a  few  months  later  we  often  find,  that 
before  the  child  has  the  power  of  mastication  the  mother  gives  the  food 
of  which  she  herself  partakes,  sometimes  adding  malt  liquors  and  ardent 
spirits.  The  consequences  of  this  dietary  are  such  as  might  be  antici- 
pated; the  food  passes  onwards  undigested,  severe  gastro-enteritis  is  in- 
duced ;  and  the  malady  is  often  aggravated  by  a  want  of  cleanliness,  and 
by  exposure  to  night  air  and  dampness.  The  mortality  in  London  from 
these  causes  is  exceedingly  great.  In  other  infants  the  food,  although  in 
itself  proper,  is  unsuited  to  the  condition  then  existing,  and  perpetuates 
diarrhoea;  or  it  may  be  that  the  milk  of  the  mother  disagrees  with  the 
child,  from  the  impairment  of  her  health.  In  such  subjects  we  occasion- 
ally find,  that  an  alteration  in  the  character  of  the  gastric  juice  of  the 
infant  leads  to  coagulation  of  the  milk,  and  to  severe  diarrhoea,  with  colic, 
etc.,  the  stools  containing  portions  of  curdled  and  undigested  milk,  namely, 
oleaginous  matter  mixed  with  casein. 

(c)  Diarrhoea  is  set  up  by  exhaustion,  either  from  want  of  food,  star- 
vation and  its  attendants  of  misery,  or  as  the  consequence  of  chronic  dis- 


88  DISEASES    OF   THE   INTESTIN^ES   AKD   PERITONEUM. 

ease.  This  form  of  diarrhoea  is  sometimes  observed  in  women  who  have 
nursed  their  infants  too  long.  Enfeebled  by  bearing  children  rapidly, 
their  strength  is  additionally  taxed  by  nursing  for  twelve,  fifteen,  or 
eighteen  months  without  proper  nourishment  or  invigorating  air.  The 
whole  mucous  membrane  is  affected;  the  nerve  of  organic  life  shows  its 
ebbing  powers;  the  blanched  cheek,  the  dilated  pupil,  the  desponding 
countenance,  and  impulses  of  a  mind  verging  on  insanity,  are  symptomatic 
of  this  condition.  There  is  intense  pain  in  the  head,  the  heart  is  enfeebled, 
the  pulse  sharp,  and  sometimes  irregular;  there  is  a  distressing  sensation 
of  exhaustion  at  the  scrobiculus  cordis,  with  severe  pain  in  the  back,  and 
in  this  state  a  very  slight  irregularity  of  food  will  sometimes  set  up 
diarrhoea  and  vomiting.  Cancerous  and  strumous  disease  of  the  mesen- 
teric glands,  obstruction  of  the  thoracic  duct,  chronic  disease  of  the 
pancreas,  diabetes,  etc.,  sometimes  have  uncontrollable  diarrhoea  as  one 
of  their  latest  symptoms. 

(d)  Epidentic  cantes. — At  some  seasons  of  the  year,  in  our  own 
climate  during  the  spring  and  autumn  months,  diarrhoea  of  varying  severity 
is  set  up,  and  appears  to  arise  from  the  condition  of  the  atmosphere,  per- 
haps from  germs  of  vegetable  or  animal  growth. 

(e)  Kndernic  cauats  are  more  numerous,  and  with  them  may  be  classed 
the  diarrhoea  arising  from  offensive  drains,  from  decaying  animal  and 
vegetable  matters.  Causes  of  this  kind  operate  with  greater  severity 
upon  the  young  and  enfeebled,  upon  the  strumous  and  ill-nourished. 
Many  infants  are  thus  affected  with  diarrhoea,  and  with  severe  general 
gastro-enteritis.  It  is  now  well  known  that  an  impure  water-supply,  es- 
pecially if  contaminated  by  sewage,  will  lead  to  diarrhoea  as  well  as  to 
enteric  fever,  and  probably  to  cholera.  Again,  a  general  dampness  of 
locality,  as  from  a  clay  subsoil,  will  set  up,  or  will  increase  and  perpetuate 
diarrhoea.  We  have  witnessed  the  removal  into  dry  bracing  air  followed 
by  cessation  of  thedisea.se,  and  the  return  to  the  same  district  repeatedly 
cause  its  recurrence. 

{f)  Excessive  secretion  of  bile,  and  other  diseases  of  the  liver,  as  well 
as  disease  of  other  intestinal  glands,  set  up  diarrhoea. 

{g)  Other  causes  are,  tubercular  disease  of  the  mucous  membrane  of 
the  intestine  and  the  mesenteric  glands;  oedema  and  long-continued  con- 
gestion of  the  mucous  membrane;  mental  agitation  and  fright;  ulceration 
of  the  small  and  large  intestine,  as  in  fever,  phthisis,  &c.  ;  cancerous  dis- 
eases; purpura  and  scurvy;  large  draughts  of  water;  miasmatic  disease; 
poisons. 

Prognos'is. — Diarrhoea  is  never  altogether  free  from  danger  in  aged 
persons,  or  in  very  young  children;  but  the  prognosis  differs  according  to 
its  cause  and  character.  If  associated  with  chronic  disease,  or  an  en- 
feebled condition  of  the  system,  it  is  often  the  immediate  precursor  of 
death;  but  when  the  cause  can  be  removed,  and  the  subject  is  young, 
however  severe  the  case  may  be,  we  should  encourage  the  prospect  of  re- 
coveiy.  Many  of  such  cases,  when  apparently  quite  in  extremis,  have 
gradually  and  almost  miraculously  recovered. 

The  prognosis  is  unfavorable,  when  diarrhoea  has  been  long-continued, 
and  is  very  severe  in  its  character;  in  some  of  these  cases  scarcely  any 
treatment  appears  to  arrest  the  purging,  and  the  patient  gradually  sinks 
into  a  typhoid  condition. 

It  may  appear  unnecessary  to  say  anything  in  reference  to  the  diarf- 
noC'is  of  diarrhrea;  it  is  well,  always,  if  possible,  to  ascertain  personally 
fbe  character  of  the  evacuations;  since  there  may  be  apparent  diarrhoea. 


DIARRHffiA.  89 

without  the  reality.  I  have  seen  starch  enemata  used  when  patients  were 
greatly  exhausted,  and,  on  inspection,  found  the  intestine  loaded  with 
solid  faecal  matter.  In  spinal  disease,  a  weak  sphincter  ani  with  involun- 
tary defecation  is  often  mistaken  for  diarrhcea,  and  I  have  known  astrin- 
gents continued  for  several  months  ineffectively,  whereas  rest  to  the  spine 
quickly  relieved  the  malady.  A  hardened  mass  of  ffeces,  which  the 
patient  is  unable  to  expel  from  the  rectum,  frequently  leads  to  the  repeat- 
ed evacuation  of  small  quantities  of  fluid  fseces  or  of  mucus,  which  is  re- 
garded as  diarrhoea  or  even  dysentery;  the  effort  at  expulsion  is  constant 
and  painful,  but  ineffective;  the  removal  of  the  mass  at  once  checks  the 
supposed  diarrhoea.  Or  again,  in  an  exhausted  state  of  the  system,  or 
during  epidemic  diarrhoea,  a  single  loose  motion  may  require  immediate 
attention ;  for  the  character  rather  than  the  quantity  should  be  our  guide. 
In  persistent  diarrhoea  it  is  important  always  to  examine  the  rectum,  for 
I  have  frequently  known  cancerous  disease  entirely  overlooked  from  the 
want  of  digital  examination, 

Ti'eatinent. — The  primary  object  must  be  to  ascertain  the  character  of 
the  diarrhoea,  and  to  remove,  if  possible,  its  cause.  If  food  be  improper, 
to  change  it,  and  administer  such  as  shall  be  of  the  least  irritating  kind. 
If  the  air  be  impure,  to  order  removal  to  a  healthy  atmosphere.  If  the 
mucous  membrane  and  the  secretions  be  disordered,  to  try  and  restore 
them  to  a  healthy  state.  To  check  the  diarrhoea  by  various  astringents 
and  by  rest. 

(a)  JVarmth. — Warm  baths,  warmth  applied  to  the  feet,  and  flannel  to 
the  abdominal  parietes,  a  warm  but  pure  air,  &c.,  assist  in  checking  many 
of  the  simpler  forms,  end  in  diminishing  those  arising  from  chronic  dis- 
ease. Local  warmth  may  be  attained  by  the  application  of  a  hot  fomen- 
tation, or  poultice  to  the  tobdomen,  or  by  such  rubefacients  as  a  mustard 
poultice,  or  turpentine  embrocation. 

(b)  Food. — In  diarrhoea  the  least  irritating  and  the  most  easily  digest- 
ible kinds  of  nourishment  are  advisable.  Many  of  the  forms  of  amylaceous 
aliment,  arrowroot,  sago,  are  of  this  kind,  and  may  be  given  made  with 
milk;  these  are  in  themselves  soothing  applications  to  irritated  mucous 
membranes,  whilst  they  serve  as  nourishment  to  the  system.  Milk,  rice, 
soaked  bread  and  toast,  lightly-boiled  puddings  of  flour  and  eggs,  &c.,  may 
be  also  taken  with  advantage,  and  in  chronic  diarrhoea  suet  and  milk  is 
often  of  great  benefit. 

(c)  The  avoidance  of  stimulants,  of  rich  and  greasy  food,  of  highly 
seasoned  dishes,  of  vegetables,  especially  when  uncooked,  of  fruits,  &c., 
is  essential;  and  it  is  well  in  many  cases  to  abstain  for  a  short  time  from 
solid  animal  food  altogether.  The  forms  of  animal  food  which  are  most 
easily  digestible  are  chicken,  sweetbread,  and  some  forms  of  fish,  as  sole, 
cod,  and  whiting;  then  venison,  mutton,  and  beef;  but  much  depends  on 
the  mode  in  which  these  viands  are  dressed.  When  dried,  salted,  and 
cold,  they  require  a  much  longer  period  for  their  digestion,  and  portions 
often  pass  into  the  intestine  undissolved.  Beef-tea  sometimes  appears  to 
increase  diarrhoea,  when  veal  and  mutton-broth  can  be  taken  with  benefit. 

(o?)  Itest,  and  the  avoidance  of  muscular  excitement  and  sudden  move- 
ments, are  very  important  in  checking  diarrhoea;  and  in  many  instances, 
especially  in  severe  cases,  a  recumbent  posture  should  be  maintained.  In 
tlie  erect  position  the  gravitation  of  fluids  increases  their  rapid  movement 
over  the  irritated  mucous  membrane. 

(e)  Pure  and  dry  air  is  very  desirable;  many  patients  at  once  recover 
when  removed  from  a  damp  atmosphere  to  a  dry  and  bracing  one;  and 


90  DISEASES   OF  THE   INTESTHTES   AND    1»ERIT0NEUM. 

when  the  contamination  of  decomposing  animal  and  vegetable  substances 
is  setting  up  the  disease,  removal  is  still  more  important,  and  is  often  es- 
sential to  permanent  restoration.  In  miasmatic  districts,  diarrhoea  may 
not  only  be  rendered  paroxysmal,  but  be  perpetuated  by  the  marsh  poison. 

Many  cases  of  diarrhoea  will  be  cured  by  this  attention  to  warmth  and 
diet,  to  rest  and  pure  air;  but  other  means  often  promote  the  comfort  and 
favor  the  restoration  to  health. 

If  the  large  intestine,  and  especially  the  rectum,  be  affected,  much 
benefit  is  derived  from  enemata.  These  are  composed  of  various  ingre- 
dients, simple  starch,  thin  gruel,  and  barley-water;  and  to  these  we  may 
add  tincture  of  opium  and  biborate  of  soda.  Or  they  may  be  made  as- 
tringent, as  decoction  of  oak  bark  with  tragacanth,  or  glycerine  of  tannin 
with  water;  or  a  very  dilute  solution  of  nitrate  of  silver  may  be  used;  an 
infusion  of  ipecacuanha  has  been  favorably  recommended  as  an  injection 
by  Boudin  and  Chouppe. 

To  restore  the  diseased  mucous  membrane  and  to  correct  secretions. — . 
(a)  The  alkalies  are  of  very  great  service  in  diminishing  congestion,  as  well 
as  in  rendering  the  secretions  less  irritating.  Solution  of  potash,  lime- 
water,  chalk,  some  salines,  as  chlorate  of  potash,  bicarbonate  of  potash, 
and  nitrate  of  bismuth,  act  in  this  manner. 

{b)  When  the  hepatic  secretions  are  disordered,  as  shown  by  furred 
tongue,  and  pale  evacuations,  the  moderate  use  of  Mercurials  is  of  value, 
as  gray  powder  or  calomel,  combined  with  Dover's  powder,  with  soda  or 
with  opium;  but  we  should  strongly  urge  that  mercurials  be  very  carefully 
administered,  because  in  many  forms  of  diarrhoea  they  tend  greatly  to 
aggravate  the  disease.  It  is  only  in  some  cases,  even  with  a  foul  tongue 
and  deficient  hepatic  secretions,  that  we  would  recommend  their  use. 

(c)  Demulcents. — These  act  by  directly  sheathing  the  mucous  mem- 
brane; the  most  important  are  those  mentioned  as  food,  but  others  are  of 
consider-able  utility,  as  acacia,  tragacanth,  linseed,  liquorice,  glycerine, 
spermaceti,  &c. 

{d)  Castor-oil,  Linseed-oil. — These  are  of  great  value,  when  improper 
food,  retained  secretions  and  scybala  irritate  the  alimentary  canal.  They 
are  combined  with  great  advantage  with  the  compound  tincture  of  rhu- 
barb, and  sometimes  with  a  small  dose  of  opium,  TUv.  or  x.  These  reme- 
dies are  of  most  service  in  some  forms  of  dysenteric  diarrhoea,  when  scy- 
bala irritate  the  mucous  membrane. 

(e)  Ipecacuanha  is  a  remedy  which  acts,  apparently,  on  all  the  mucous 
membranes,  and  is  as  valuable  in  disease  of  the  alimentary  as  of  the  re- 
spiratory mucous  membrane.  Ipecacuanha  not  only  increases  the  quantity 
of  mucus  but  it  mitigates  inflammatory  congestion.  It  is  of  great  service 
in  the  dysenteric  diarrhoea  of  adults,  and  equally  so  in  the  diarrhoea  of 
infants.  In  the  former,  Dover's  powder  is  a  valuable  form  for  its  admin- 
istration, or  the  ipecacuanha  may  be  combined  with  astringents,  as  in  the 
compound  infusion  of  krameria,'  and  the  compound  logwood  mixture  of 
the  Guy's  Pharmacopoeia,  or  it  may  be  administered  alone,  as  in  the  treat- 
ment of  pure  dysentery. 

(/■)  Astringents  and  Desiccants. — These  may  be  divided  into  several 
classes.  The  saline,  as  chalk;  the  vegetable,  as  tannic  and  gallic  acids, 
krameria,  kino,  catechu,  logwood,  Indian  bael,  cusparia,  opium;  metallic,  as 
sulphate  of  copper,  acetate  of  lead,  nitrate  of  silver,  nitrate  of  bismuth,  &o. 

'  iDfnsam  Kramerise  compositam.    Inf  asion  of  EhatAiiy  Boot,  fl.  %  xj.  ;  Ipecacuanha 
Wine,  3  iv. ,  Tincture  of  Catechu,  3  iv. 


DIARRH(EA.  91 

J 

{(/)  Opium  acts  not  only  as  an  astringent,  but  also  as  a  narcotic;  it  di- 
minishes the  secretion  from  the  mucous  membrane,  and  the  peristaltic 
movement  of  the  intestine,  and  it  relieves  the  pain  of  colic.  It  is  of  great 
value  in  diarrhoea,  and  may  be  combined  with  other  remedies,  as  with 
chalk  and  ipecacuanha;  but,  when  irritating  ingesta  and  disordered  se- 
cretions perpetuate  diarrhcea,  opium  and  astringents  are  not  appropriate 
remedies.  When  the  disease  is  chronic,  opium  may  be  given  with  the 
more  active  vegetable  astringents,  catechu,  kratneria,  and  logwood,  and 
sometimes  very  advantageously  with  quinine. 

The  metallic  astringents  are  combined  in  a  similar  manner  with  opium 
and  ipecacuanha,  but  are  more  frequently  used  in  chronic  dysentery,  and 
ill  tubercular  ulceration  of  the  intestine,  than  in  simple  diarrhcea. 

(A)  Mineral  Acids, — Much  has  been  written  upon  the  use  of  dilute 
sulphuric  acid  in  diarrhcea  ;  and  its  use  has  certainly  been  attended  with 
benefit,  although  not  to  the  extent  we  were  led  to  suppose.  Both  dilute 
sulphuric  acid,  and  dilute  nitric  acid,  are  of  value  after  the  more  severe 
symptoms  have  passed  off ;  they  act  at  first  possibly  by  checking  chemi- 
cal and  fermentative  changes,  and  afterwards  as  tonics  to  the  relaxed 
mucous  membrane.  Combined  with  slightly  astringent  and  mucilaginous 
tonics,  as  with  cusparia  and  simaruba,  or  with  calumba  root  and  elm  bark, 
they  are  of  great  service  in  some  cases. 

When  there  is  much  pain  we  may  associate  narcotics  with  other  reme- 
dies before  mentioned.  Spirit  of  chloroform  and  spirit  of  camphor  in 
small  doses  sometimes  afford  great  relief,  so  also  the  tincture  of  henbane; 
in  other  cases  simple  carminative  medicines  are  sufficient  to  relieve  the 
pain,  as  ginger,  cardamoms,  &c.,  especially  where  the  diarrhcea  is  associ- 
ated with  flatulent  colic. 

In  the  colliquative  diarrhcea  of  weaned  children  Dr.  I.  F.  Weisse  has 
strongly  advocated  the  administration  of  raw  meat,  scraped  and  reduced 
to  a  pulp,  as  we  have  previously  mentioned  in  the  remarks  on  enteritis. 

(i)  Leeches. — The  application  of  leeches  to  the  anus  is  a  remedy  which 
greatly  relieves  inflammatory  congestion  of  the  mucous  membrane  of  the 
large  intestine,  but  it  is  one  which  we  should  scarcely  recommend,  unless 
the  disease  assume  a  severe  and  dysenteric  character. 

(J)  Suppositories,  composed  of  the  compound  soap  pill  or  morphia,  are 
often  of  great  service  when  there  is  distressing  tenesmus  which  disturbs 
the  rest  of  the  patient;  and  when  it  is  undesirable  to  administer  an  opiate 
by  the  mouth,  or  inconvenient  to  use  an  enema.  Tannin  may  also  in  this 
way  be  conveniently  used,  so  also  bismuth. 

In  chronic  mucous  discharge  from  the  bowels,  we  must  first  seek  to 
remove  the  disease  of  the  liver,  if  such  exist,  by  mild  alteratives,  by  tar- 
axacum, and  by  nitro-muriatic  acid.  These  remedies,  also,  assist  in  re- 
lieving the  chronic  congestion  and  inflammation  of  -the  intestine,  and  are 
more  effective  than  astringents.  It  is  well,  however,  to  be  assured  that 
no  polypoid  growth,  nor  disease  of  the  rectum  and  sigmoid  flexure,  is 
setting  up  the  disease. 

If  astringents  be  required  in  these  instances,  the  oxide  and  nitrate  of 
silver,  sulphate  of  copper  with  opium,  or  the  vegetable  astringents  just 
mentioned,  may  be  used;  and  as  enemata,  glycerine  of  tannin  diluted 
with  water,  the  solution  of  nitrate  of  silver  (gr.  x. — xv.  to  Oj.*),  the  in- 
fusion of  quassia,  the  decoction  of  oak  bark,  and  the  decoction  of  poppies 
with  or  without  the  addition  of  borax,  may  be  employed  with  advantage. 

*  Trousseau. 


92  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

In  the  treatment  of  choleraic  diarrhcea,  rest  in  the  recumbent  position, 
warmth  to  the  abdomen  and  the  feet,  and  gentle  friction,  if  muscular 
spasm  distress  the  patient,  are  valuable  remedies.  A  full  dose  of  chalk 
and  opium  with  catechu  and  aromatic  spirit  of  ammonia  should  be  given, 
and  repeated  in  two  or  three  hours,  if  necessary.  Demulcent  nutriment, 
as  mutton-broth  and  arrowroot,  may  be  allowed;  and  if  vomiting  super- 
vene, ice  or  cold  water  will  be  beneficial.  Dilute  sulphuric  acid  has  been 
sometimes  used  with  great  advantage,  and  by  some  calomel  has  been 
freely  given  in  these  cases,  especially  when  vomiting  has  come  on.  When 
the  collapse  of  true  cholera  has  attacked  the  patient,  general  experience 
does  not  favor  the  free  use  of  either  opium  or  brandy;  but  to  enter  fully 
into  the  treatment  of  cholera  is  foreign  to  our  purpose. 

The  following  cases  of  diarrhoea  are  of  considerable  interest: 

Case  CXXV. — Inanition.  Diarrhoea. — John  M ,  ?et.  26,  was  ad- 
mitted into  Guy's  Hospital  Dec.  17th,  1856,  and  died  Dec.  20th.  He  had 
been  a  sailor,  and  stated  that  he  had  had  dysentery,  but  this  was  not  sat- 
isfactorily ascertained,  on  account  of  his  prostrate  condition.  It  appeared 
that  he  had  been  on  board  an  American  vessel  from  China  to  Liverpool, 
and  arrived  at  the  latter  place  on  December  6th;  he  then  came  up  to 
London.  He  informed  the  nurse  that  there  had  been  a  mutiny  on  board, 
and  that  he  had  been  put  in  irons  in  the  hold.  He  was  in  the  most 
emaciated  state;  the  voice  was  scarcely  perceptible;  the  pulse  was  exceed- 
ingly compressible,  and  the  tongue  and  mouth  presented  yellowish  white 
aphthous  patches;  he  had  no  vomiting,  but  the  stools  escaped  from  him, 
and  were  white  and  very  offensive;  the  respiration  was  easy,  and  the  mind 
perfectly  conscious.  Milk  was  ordered.  The  following  day  he  was 
better,  but  sank  on  the  third  day  after  admission,  and  was  sensible  tiL 
nearly  the  last. 

Inspection,  December  22,  1856. — There  were  ecchymoses  on  both 
thighs,  and  old  cicatrices  on  the  wrist  and  leg.  The  brain  was  less  firm 
than  normal;  the  lungs  were  collapsed  and  healthy.  The  heart  was 
small.  The  liver  was  healthy.  The  gall-bladder  was  not  distended,  and 
the  spleen  and  kidneys  were  healthy.  The  stomach  presented  gastric 
solution  at  the  cardiac  portion.  The  small  intestines  were  healthy.  The 
large  intestine  was  throughout  of  a  gray  color,  and  was  filled  with  dry, 
white  fasces.  At  the  root  of  the  mesentery  were  several  white  stru- 
mous masses  in  the  glands,  but  it  could  not  be  found  that  the  thoracic 
duct  was  obstructed.     The  urinary  bladder  was  distended. 

This  case  presents  us  with  a  well-marked  instance  of  a  man  dying 
from  the  effect  of  starvation.  The  diarrhoea  was  probably  the  result  of 
want  of  nourishment,  of  good  air,  and  of  light,  «&c. ;  so  that  supplies  hav- 
ing been  cut  off  and  the  conditions  necessary  for  reparation  excluded,  the 
whole  body  wasted,  and  the  spark  of  life  gradually  expired. 

Case  CXXVT. —  Chronic  Diarrhoea.     Hysteria.     Great  Relief  from 

Tincture  of  Iron. — Georgiana   B ,  vat.  40,  a  single  woman,  who  had 

resided  in  the  Commercial  Road,  and  had  supported  herself  by  her  needle, 
applied  at  Guy's  Hospital  May  23,  1860,  and  was  admitted  under  my 
care.  She  had  suffered  from  uterine  ulceration.  During  eighteen  months 
she  had  been  affected  with  diarrhoea,  and  when  she  had  mental  anxiety 
the  disease  increased  in  severity.  The  slightest  exertion  produced  per- 
spiration.    She  was  a  tall  woman,  extremely  nervous,  the  eyes  sunken, 


DIARBHCEA.  93 

the  countenance  dejected.  The  heart  and  lungs  were  normal.  She  com- 
plained of  great  pain  in  the  abdomen,  on  the  right  side  below  the  liver, 
in  the  region  of  the  ascending  colon;  there  was  tympanitic  distention  in 
the  same  region;  the  bowels  were  opened  six  times  in  twenty-four  hours, 
but  there  was  no  evidence  that  blood  had  been  passed.  She  had  not 
taken  meat  during  several  months.  Astringents  of  different  kinds  were 
administered  and  enemata  used,  with  only  partial  relief,  till  the  tincture 
of  iron  was  given  persistently  for  several  weeks.  The  diarrhoea  then 
subsided,  and  she  left  the  hospital  convalescent,  stating  that  she  had 
not  been  so  well  for  eight  years. 

This  case  appeared  to  be  one  of  passive  mucous  diarrhoea  in  a  very 
hysterical  subject,  and  the  uterine  irritation  had  tended  to  perpetuate 
the  disease.  Astringents  were  less  efficacious  than  preparations  of  steel, 
which  diminished  the  nervous  irritability  and  gave  tone  and  strength  to 
the  whole  system.  The  regulated  and  more  generous  diet  which  was 
given  must  not  be  overlooked;  and  by  persuasive  measures  she  was  in- 
duced to  take  a  meat  diet,  which  lessened  the  fluid  contents  of  the  colon, 
and  thereby  increased  the  consistence  of  the  alvine  discharges. 


DYSENTERY. 

By  J.  Warbueton  Begbik,  M.D.,  F.R.C.P.E. 


DEFTNTnON. — A  febrile  disease,  in  which  inflammation  affecting  the 
glandular  structures  of  the  large  intestine  chiefly — although  sometimes 
extending  to  the  small — and  producing  ulceration,  tends  to  terminate  in 
sloughing  of  the  mucous  membrane.  The  disease  is  accompanied  by 
much  nervous  depression,  and  is  characterized  by  tormina — severe  pains 
in  the  abdomen  of  a  griping  nature — followed  by  frequent  scanty  and 
bloody  stools,  straining,  and  tenesmus. 

The  term  Dysentery  is  derived  from  two  Greek  words — 8vs,  hard  or 
bad,  and  Ivrepov,  a  piece  of  the  guts,  intestines.  Avo-cn-cpia,  was  itself  em- 
ployed by  Hippocrates  and  other  Greek  writers  to  signify  a  bowel  com- 
plamt,  or  bloody  flux. 

Synonyms. — Tormina;  Tormina  intestinorum ;  Fluxus  dysentericus; 
Fluxus  cruentus;  Fluxus  torminosus;  Rheuma  ventris;  Febris  dysenter- 
ica;  Colonitis;  Bloody  Flux;  Dysenteria;  Flux  de  Sang  (French);  Die 
Ruhe,  Die  rothe  Ruhe  (German);  Dissenteria  (Italian);  Dysenteria 
(Spanish). 

History. — Dysentery  has  been  known  as  a  disease  since  the  earliest 
period  of  medical  history.  In  several  of  the  Hippocratic  treatises,  but 
especially  in  the  following, — Uepl  deptuv,  vSultwv,  koI  tottwv,  IIpoyvaxrTiKov,  and 
'Ac^optcr/xot, — are  many  interesting  remarks  regarding  the  symptoms  and 
treatment  of  Dysentery,  also  the  prognosis  to  be  founded  upon  it,  to  be 
met  with.  Aret^us  has  described  Dysentery  with  his  usual  conciseness, 
and  even  more  than  his  usual  ability.  In  Cajiius  Aurelianus,  but  still 
more  in  Celsus,  much  information  may  be  found  regarding  Dysentery,  as 
the  disease  was  known  in  the  days  of  these  celebrated  Latin  writers. 
Coming  down  to  modern  times,  Sydenham,  Ramazzini,  Morton,  Huxham, 
Cleghorn,  Morgagni,  Zimmerman,  and  Sir  John  Pringle  (in  his  celebrated 
treatise  on  Diseases  of  the  Army),  are  among  the  more  distinguished  of 
the  numerous  writers  on  Dysentery.' 

Dysentery  is  placed  by  Cullen  in  class  first,  "  Pyrexiae,"  and  of  it  the 
fifth  order,  "  Profluvia."  Of  the  latter  his  definition  is  "  Pyrexia  cum  ex- 
cretione  aucta  naturaliter,  non  sanguinea."  Dysentery,  Cullen  defines  as 
follows:  "Pyrexia  contagiosa;  dejectiones  frequentes,  mucos£B,  vel  san- 
guinolentas,  retentis  plerumque  fa3cibus  alvinis;  tormina;  tenesmus."  ' 

It  is  customary  to  distinguish  between  acute  and  chronic  Dysentery, 
also  betVeeerj  epidemic  and  non-epidemic  or  sporadic  Dysentery.     To  the 

'  For  a  full  and  instructive  account  of  the  history  and  geographical  distribution  of 
Dysentery,  see  Hirsch,  "  Handbuch  der  historisch  geographischen  Pathologic,"  article 
'"Huhe,"  vol.  ii.  p.  104. 

*  Synopsis  Nosologie  Methodicae,  p.  308. 


96  DISEASES    OF   THE   INTESTINES    AND   PERITONEUAI. 

non-epidemic  disease  we  are  now  to  direct  attention — the  epidemic  Dysen- 
tery having  been  already  considered  by  Dr.  Maclean. 

Symptomatology. — The  essential  characters  of  Dysentery  are  severe 
pains  of  a  griping  nature  in  the  belly,  followed  by  frequent  and  bloody 
stools,  defecation  being  accompanied  by  much  straining  and  tenesmus. 
The  later  symptoms  are  the  most  characteristic.  Watch  a  patient  af- 
fected by  Dysentery  at  stool:  he  sits  a  long  time,  straining;  his  features 
are  distorted  by  the  pain  he  suffers;  the  discharge  from  the  bowels  may 
be,  often  indeed  is,  but  scanty:  still  he  sits.  The  strong  desire  to  remain 
at  stool,  aco<}mpanied  by  griping  and  straining,  is  expressed  in  the  word 
tenesmus.  Scarcely  can  such  patients  at  times  be  persuaded  to  leave  the 
stool  and  return  to  bed,  until  they  feel  so  faint  as  to  be  unable  longer 
to  maintain  the  sitting  posture,  and  sometimes  while  on  the  stool  they 
faint. 

Straining  and  tenesmus  do  not  occur  in  diarrhoea,  they  are  peculiar  to 
dysentery;  and  so  also  are  the  other  symptoms,  named  in  Cullen's  defini- 
tion; the  passage  of  blood  and  mucus,  the  faeces  being  for  the  most  part 
retained,  or  after  a  time  passed  in  the  form  of  small,  often  hard,  scybala. 

Aciite  Dysentery. — The  disease  in  this  form  may  occur  without  any 
premonitory  symptoms;  more  commonly,  however,  it  is  preceded  by  such. 
General  uneasiness,  lassitude,  impaired  appetite,  disagreeable  sensations 
in  the  abdomen,  confined  bowels,  or  a  loose  condition  of  the  bowels,  are 
among  the  more  frequent  of  the  premonitory  symptoms.  These  may 
have  existed  for  a  few  days,  when  a  chill  is  experienced,  or  sometimes  a 
chill  or  rigor  is  the  very  earliest  indication  of  departure  from  a  healthy 
state.  To  these  succeed  the  febrile  symptoms,  heat  of  skin  and  quickness 
of  the  pulse.  Much  variety  exists  in  respect  to  the  degree  of  the  general 
or  constitutional  disturbance  which  accompanies  the  local  affection  in 
Dysentery.  That  may  be  very  slight  indeed;  the  disease  may  even  run 
its  course  without  fever.  On  the  other  hand,  the  constitutional  disorder 
may  be  severe,  and  is  not  unfrequently  profound,  assuming  an  adynamic 
or  typhoid  character.  In  the  simpler  variety  of  the  disease,  there  are  at 
■the  commencement  griping  pains  in  the  belly,  those  pains  to  which  the 
«name  of  "  tormina  "  is  now  generally  applied.  This  term  was  first  used 
by  Celsus.'  "  Proxima,"  he  says,  "  his  inter  intestinorum  mala  tonnina 
esse  consueverunt:  Swo-cvrepia  Graece  vocatur."  The  tormina  are  felt  in 
different  parts  of  the  belly,  and,  like  the  pain  of  colic,  yield  at  one  time, 
to  return  again,  perhaps  more  severely  than  before.  With  the  tormina 
there  occur  discharges,  usually  slight,  from  the  bowels,  and  by  these  a 
partial  relief  to  the  pain  is  experienced.  To  the  tormina  and  diarrhcea 
succeeds  the  tenesmus;  and  this  term  may  be  understood  as  including  the 
frequent  desire  to  go  to  stool,  and  the  reluctance  to  leave  it,  with  the 
very  distressing  feeling  of  bearing  down,  and  burning  sensation  in  the 
rectum.  In  every  marked  case  of  Dysentery  the  tenesmus  is  a  jirominent 
as  it  is  the  most  distressing  symptom.     The  discharge  from  the  bowels 

'  Liber  iv.  ch.  xv.  The  description  of  the  disease  given  by  Celsus  is  so  accurate  as 
to  merit  perusal ;  the  earlier  sentences  may  le  quoted.  "  Intus  intestina  exuloeran- 
tar ;  ex  his  cruor  manat,  isque  modo  cum  stercore  aliquo  semper  liquido,  niodo  cura 
quibusdam  quasi  mucosis  excernitur;  interdum  simul  quaedam  carnosa  descenduiit; 
frequens  dejiciendi  cupiditas,  dolorque  in  ano  est;  cum  eodem  dolore  exiguum  ali- 
qnid  emittitur  ;  atque  eo  quoque  tormentum  indenditur;  itque  post  tempus  aliquod 
levator;  exigua  requies  est ;  somnus  intt;rpellatur ;  febricula  oritur;  longoque  tem- 
pore id  malum,  cum  iuvetcraverit  aut,  tollit  homiuem  aut,  etiamsi  finilur,  cxcru- 
clac." 


DYSENTERY.  97 

affords  little  relief  when  the  tenesmus  is  great.  The  calls  to  stool  of  course 
vary  greatly  in  frequency:  in  some  instances  they  are  almost  incessant. 
Occurring  in  children,  particularly,  but  occasionally  also  in  adults,  as  a  con- 
sequence of  the  frequent  evacuations,  and  the  tenesmus  by  which  they 
are  accompanied,  is  prolapsus  of  the  anus,  which  in  itself  requires  care- 
ful management,  and  may  become  a  very  troublesome  sequela  of  the  dis- 
ease.' 

The  discharges  from  the  bowels  in  Dysentery  are  peculiar  and  charac- 
teristic. At  first  they  are  usually  feculent,  if  not  entirely,  at  least  chiefly 
so;  but  very  soon,  becoming  very  scanty  in  amount,  they  are  found  to  be 
composed  of  mucus,  or  of  mucus  mixed  with  blood,  and  sometimes  of 
nearly  pure  blood.  When  the  inflammation  of  the  bowels  has  advanced 
to  a  certain  stage,  it  is  common  to  notice  the  appearance  of  vitiated  bile 
in  the  stools,  and  likewise  of  shreddy-looking  portions  of  fibrine  or  false 
membrane.  The  odor  of  the  evacuations  in  Dysentery  is  one  sui  generis, 
quite  peculiar,  and  highly  offensive.  Not  unfrequently  there  is  sympa- 
thetic irritation  of  the  bladder,  and  a  frequent  as  well  as  difiicult  micturi- 
tion. While  the  chief  part  of  the  pain  in  Dysentery  is  experienced  during 
the  movement  of  the  bowels,  it  is  not  limited  to  that  time — pain  is  present 
in  the  abdomen  generally  aggravated  by  pressure.  When,  in  addition  to 
the  tenderness  over  the  left  side  of  the  belly,  corresponding  to  the  posi- 
tion of  the  sigmoid  flexure,  there  is  pain  felt  over  the  epigastrium  and 
down  the  right  side,  it  may  be  conjectured  that  the  disease  has  implicated 
the  large  intestine  in  its  entire  extent,  and  is  not  limited,  as  happens  in 
milder  instances,  to  the  rectum  and  descending  portion  of  the  colon. 

More  or  less  of  fever  accompanies  Dysentery.  In  mild  cases  the  fever- 
ish disturbance,  as  already  stated,  is  slight,  but,  on  the  other  hand,  in  the 
more  decided  instances  of  the  disease,  the  constitutional  disturbance  is 
evidenced  by  the  quickness  of  the  pulse,  the  augmented  temperature  of 
the  surface  scanty  secretion  of  urine,  and  the  coated  condition  of  the 
tongue.  In  the  milder  cases  of  Dysentery  there  is  no  special  implication 
of  the  nervous  system;  the  pulse  in  such,  although  frequent,  is  full  and 
of  good  strength :  neither  nausea  nor  vomiting,  except  of  occasional  occur- 
rence, are  present;  and  although  the  local  malady  may  be  severe,  the  dis- 
ease wears  throughout  a  sthenic  character.  But  it  is  not  always  so;  an 
asthenic  or  adynamic  form  of  Dysentery  also  occurs,  characterized  by  a 
frequent,  small,  and  feeble  pulse,  pallor  and  coolness,  rather  than  warmth 
of  the  skin,  the  occurrence  of  a  clammy  moisture  over  it,  anxious  expres- 
sion of  the  countenance,  sunken  eyes,  dryness  and  glazing  of  the  tongue, 
suppression  of  the  voice,  hiccough,  delirium,  prominence  of  the  abdomen 
and  rapid  sinking.  With  these  indications  there  is  unusual  violence  in 
the  local  symptoms,  particularly  as  regards  the  frequency  of  the  discharges 
from  the  bowels.  These  ultimately  become  exceedingly  offensive  and 
watery.  They  present  the  appearance  of  water  in  which  raw  flesh  has 
been  washed,  and  are  known  by  the  name  of  "  lotura  carnium."  The  dis- 
ease may  thus  prove  fatal  in  a  few  days.  Dr.  Wood  speaks  of  such  cases 
as  very  rare,  and  only  seen  during  epidemics.*  The  latter  observation  is 
no  doubt  correct,  but  only  to  a  certain  extent,  for  these  instances  of  rap- 

'  "  Durch  die  heftigen  Anstrengungen  wird  auch  nicht  selten,  zumal  bei  Kindern, 
ein  Prolapsus  ani  herbeigefiihrt  der  sich  entweder  von  selbst  weider  zuriickzieht  oder 
reponirt  werden  muss." — Uenocu,  Klinik  der  U iiterleibs-Kranklieiten,  Ruhe,  Band  ;J, 
p.  235. 

*  A  Treatise  on  the  Practice  of  Medicine.  By  George  B.  Wood,  M.D.  VoL  1.  p. 
625. 

7 


98  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

idly  fatal  dysentery,  although  more  common  in  the  epidemic  prevalence 
of  the  disease,  are  occasionally  met  with  in  the  non-epidemic  malady.  It 
has  occurred  to  the  writer  to  witness  one  or  two  very  rapidly  fatal  cases 
of  Dysentery,  in  which  a  remarkable  depression  of  the  nervous  system 
was  evident  from  the  very  commencement  of  the  disease.  In  the  ordinary 
form  Dysentery  tends  to  a  favorable  termination,  and  usually  before  the 
lapse  of  a  week  or  eight  days  there  are  indications  of  amendment.  The 
acute  disease  sometimes  terminates  in  chronic  dysentery. 

Chronic  Dysentery  is  characterized  by  the  frequency  of  the  evacua- 
tions, which,  at  the  same  time,  are  usually  very  scanty.  As  in  the  acute 
affection,  so  in  the  chronic,  the  discharges  are  attended  by  local  suffering 
and  tenesmus.  Mucus,  or  mucus  mixed  with  blood,  sometimes  with  puru- 
lent matter,  constitutes  the  bulk  of  the  evacuations;  feculent  stools  occur 
when  the  disease,  instead  of  implicating  the  entire  colon,  is  limited  to  the 
rectum,  or  involves  with  it  only  the  descending  portion  of  the  former. 
Chronic  dysentery  may  last  for  months  or  years.  In  some  instances  it 
appears  to  produce  wonderfully  little  influence  on  the  general  health  and 
strength  of  the  invalid,  but  as  a  general  rule  the  sufferer  from  chronic 
dysentery  is  emaciated,  pale,  and  weakly;  and  the  disease  is  not  unapt  to 
prove  fatal,  through  the  exhaustion  consequent  upon  its  long  continuance, 
or  owing  to  the  establishment  of  a  state  of  continual  or  hectic  fevor. 

Among  the  morbid  conditions  which  are  connected  with,  or  result  from, 
attacks  of  Dysentery,  whether  acute  or  chronic,  affections  of  the  liver  oc- 
cupy a  chief  place,  and  to  these  attention  will  be  called  in  treating  of  the 
pathological  anatomy  of  the  disease.  Anaemia,  more  or  less  marked, 
results  from  Dysentery.  The  writer  remembers  to  have  seen  a  case  of 
anaemia  of  a  very  typical  character,  in  which  the  blood  impoverishment 
was  due  to  a  long-continued  attack  of  Dysentery.  To  the  occurrence  of 
paralysis  in  conjunction  with  Dysentery,  Romberg  has  called  attention,' 
and  he  quotes  a  passage  from  an  old  dissertation  by  Fabricius:  "  De  paralysi 
brachii  unius  et  pedis  alterius  lateris  dysentericis  familiari,"  *  in  verifica- 
tion of  the  remark.  J.  P.  Frank  refers  to  the  same  occurrence;'  and 
although  Graves  *  has  not  specially  mentioned  Dysentery  as  a  form  of  in- 
testinal disease  giving  rise  to  a  reflex  paraplegia,  he  has  emphatically  done 
so  in  reference  to  Enteritis.  By  Zimmerman*  and  Joseph  Frank'  allusion 
is  made  to  paralysis  of  the  arms  and  legs  occurring  after  Dysentery. 

MoEBiD  Anatomy. — As  Dysentery  is  essentially  a  disease  of  the  large 
intestines  it  is  in  the  colon  and  rectum  that  we  look  for  the  morbid  ap- 
pearances characteristic  of  its  occurrence.'     The  mucous  membrane  in  these 

'  "  Anchbei  derDysenterie,"  remarks  Romberg,  "  ist  das  Vorkommen  der  Paralyse 
beobachtet  worden." — Lehrbrich  der  Nervenkrankheiten  dea  Meiischen:  Spinale  Lah- 
mungen. 

'  Dispntationes  ad  Morbomm  Historiam  et  Curationem  fauientes  quas  coUegit 
edidit,  et  recensuit  Albertus  Haller.     Tomus  primus,  p.  97. 

*  "Tantum  vero  ad  grradum  doloris  in  abdomine  vehementia  apnd  hos  vel  illos 
evehitnr,  nt  ab  eo  non  minns  ac  in  colica  satumina  brachii  aut  pedis  unias  vel  alterius 
paralysis  sequatur." — De  Gurandis  Homiaum  Morbia.  Auctore  Joanne  Petro  Frank, 
Liber  v.  De  Profluviis,  pars  ii.  p.  497. 

*  Clinical  Lectures,  Edition  1 864,  in  one  vol.  p.  41 5. 
'  Von  der  Rahe  unter  kem  Volke  in  Jahr  1765. 

*  Praxios  Medicae  UniversaB  Praecepta.     Auctore  Josepho  Frsmk.     D«  Paralysi. 

'  The  mucous  membrane  of  the  colon,  says  Rokitansky,  is  the  seat  of  the  dysenteric 
process ;  and  we  may  state  it  as  a  rule,  that  its  intensity  increases  from  the  ciecal 
valve  downwards,  and  oonsequently  is  met  with  in  the  most  fully-developed  state  in 
tlid  sigmoid  flexure  and  in  the  rectum.  It  not  unfrequently  passes  beyond  the  ctecal 
valve  towards  the  ileum,  but  is  here  only  seen  in  its  mildest  form. 


DYSENTERY.  99 

portions  either  presents  the  appearance  of  having  been  diffusely  inflamed, 
being  everywhere  much  reddened,  thickened,  and  at  parts  ulcerated,  or, 
with  the  absence  of  diffuse  inflammation,  there  exists  remarkable  promi- 
nence of  the  solitary  glands  and  mucous  follicles.  There  exist  three  separate 
and  distinct  forms  of  ulceration  affecting  the  mucous  surface  of  the  intes- 
tines— the  tubercular,  the  typhoid,  that  met  with  in  enteric  fever,  and  the* 
dysenteric.  Apart  from  other  characteristic  differences  in  these  affections,, 
the  last-mentioned  is  nearly  limited  in  its  occurrence  to  the  large  bowel, 
while  the  two  former  are  especially  met  with  in  the  small  intestines,  and 
particularly  in  the  ileum.  The  size  of  dysenteric  ulcers  varies.  They  are 
sometimes  small,  and  present  a  nearly  circular  form,  or  they  are  larger, 
irregular  in  shape,  having  an  abrupt  border,  are  covered  by  a  dark-colored 
slough,  and  appear  as  if  formed  by  the  coalescence  of  several  smaller 
ulcers.  It  is  not  uncommon  to  find  considerable  portions  of  more  or  less 
dense  lymph,  coating  the  reddened  and  thickened  mucous  surface.  Por- 
tions of  false  membrane  having  precisely  the  same  appearance  are  some- 
times passed  at  stool;  but  these,  while  still  adherent  to  the  bowel,  do  not 
when  removed  usually  disclose  an  ulcerated  surface.  A  truly  sphacelated 
condition  of  the  mucous  membrane  is  occasionally  met  with,  and  pieces 
of  gangrenous  mucous  membrane,  sometimes  of  considerable  size,  have 
been  passed  in  the  evacuations  in  certain  cases  of  Dysentery.  Perforation 
of  the  bowel,  which  is  of  no  uncommon  occurrence  in  the  progress  of 
typhoid  ulceration,  and  occasionally  takes  place  in  tubercular  disease  of 
the  bowels,  is  very  rarely  indeed  met  with  in  Dysentery:  the  mucous, 
sub-mucous,  and  muscular  coats  of  the  colon  suffer  in  this  disease,  but 
the  peritoneal  covering  is  not  so  apt  to  be  involved.  The  mesenteric  glands 
in  Dysentery  are  frequently  found  tumefied  and  presenting  a  dark-bluish 
color.  They  may  be  softened,  but  are  very  rarely  indeed  the  seat  of  sup- 
puration. Even  when  much  enlarged,  they  have  not  been  distinguished 
by  the  presence  of  any  peculiar  morbid  product  such  as  occurs  in  the 
typhoid  and  tubercular  tumefactions  of  these  glands.  Rokitansky  describes 
the  dysenteric  process  as  divisible  into  four  natural  degrees  or  forms.*  The 
anatomical  characters  of  the  first  or  lowest  form  are,  swelling,  injection, 
and  reddening,  softening  (red  and  bleeding),  serous  exudation  in  the 
shape  of  a  delicate  vesicular  eruption,  and  consequent  branny  desquama- 
tion of  the  epithelium  (the  latter  appearance  probably  led  Linnaeus  to 
term  Dysentery  "  Scabies  intestinorum  interna  ").  In  the  second  form,  a 
larger  surface  of  the  bowel  is  involved,  but  still  presenting  a  deeper  de- 
velopment at  one  part  than  another — there  is  copious  infiltration  of  the 
sub-mucous  cellular  tissue,  giving  rise  to  a  greater  or  less  number  of 
prominences,  which  correspond  to  those  parts  of  the  mucous  membrane  at 
which  the  morbid  process  is  most  conspicuous.  The  intestine  is  generally 
in  a  state  of  passive  dilatation,  distended  by  gas,  and  occupied  by  a  dirty- 
brown  fluid,  composed  of  intestinal  secretions,  epithelium,  lymph,  blood, 
and  fseces.  The  coats  of  the  bowel  are  thickened,  and  the  sub-mucous 
tissue  especially  in  a  state  of  tumefaction.  In  the  third  stage,  the  prom- 
inences are  more  thickly  set,  and  the  result  is  an  uneven  lobulated  ap- 
pearance. The  mucous  membrane  investing  these  prominences  is  in  part 
converted  into  a  slough,  or  it  may  have  disappeared,  so  as  to  expose  the 
infiltrated  sub-mucous  cellular  tissue  to  which  the  remnants  of  the  mucous 
membrane  remain  attached,  in  the  shape  of  solitary  dark-red,  flaccid,  and 
bleeding  vascular  tufts,  or  as  dilated  follicles  which  are  capable  of  easy 

'  A  Manual  of  Pathological  Anatomy.     Sydenham  Society's  Edition,  vol.  ii.  p.  83. 


100         DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

removal.  The  contents  of  the  intestine  are  now  of  a  dirty-brown  or  red 
dish,  ichorous,  fetid,  flocculent  and  grumous  character.  In  the  fourth  and 
highest  degree,  the  mucous  membrane  has  degenerated  into  a  black,  fri- 
able, carbonified  mass,  j)ortions  of  which  may  be  subsequently  voided  in 
the  shape  of  tubular  laminae  (so-called  mortification  of  the  mucous  mem- 
brane). The  sub-mucous  cellular  tissue  appears  to  be  infiltrated  with  sero- 
sanguinolent  fluid,  or  dark  blood;  or  it  is  pale,  and  the  blood  contained 
in  its  vessels  is  converted  into  a  black  solid  mass.  Purulent  infiltration 
of  the  sub-mucous  tissue  is  also  found.  The  affected  portion  of  the  bowel, 
which  contains  a  putrid  fluid  resembling  coffee  grounds,  may  be  either  in  a 
state  of  passive  dilatation,  or  (and  this  is  more  frequently  the  case)  col- 
lapsed. In  the  higher  degrees  of  the  dysenteric  process  the  muscular 
coat  of  the  colon  suffers;  its  tissue  becomes  condensed,  pale,  ashy,  and 
friable.  In  the  same  degrees,  the  peritoneal  covering  does  not  completely 
escape,  it  presents  a  dirty-gray  discoloration,  has  lost  its  lustre,  and  here 
and  there  dilatation  and  injection  of  its  capillary  vessels  is  visible,  while 
occasionally  it  is  covered  by  a  thin  brownish  ichorous  exudation.  These 
characters  afford  the  means  of  recognizing  the  existence  of  an  advanced 
stage  of  Dysentery,  while  as  yet  the  intestine  has  been  unopened,  and 
the  mucous  surface  unexposed.  Rokitansky  has  some  very  interesting 
observations  on  the  termination  of  Dysentery.  Provided  disorganization 
of  the  mucous  membrane  has  not  occurred,  a  cure  results  through  the 
return  of  normal  cohesion,  and  the  generation  of  a  new  layer  under  the 
desquamated  epithelium.  In  the  more  intense  degrees  of  the  dysenteric 
process,  and  when  disorganization  has  taken  place,  the  mucous  membrane 
having  undergone  more  or  less  destruction,  one  or  two  results  ensues — 
either  a  real  cure  of  the  loss  of  substance,  with  consolidation  of  the  abraded 
portions  of  the  intestine,  follows,  or  the  entire  process  assumes  a  low 
chronic  form,  the  specific  nature  of  the  disease  is  lost,  and  an  inflammation 
Atonic  in  character,  with  suppuration  of  the  intestinal  coat,  occurs.  Dys- 
entery is  fatal  through  the  more  or  less  rapid,  or  more  or  less  penetrating, 
destruction  of  tissue  and  coincident  exhaustion.  When  cure  results,  the 
loss  of  substance  having  been  inconsiderable,  new  tissue  is  formed,  and 
may  so  contract  as  to  bring  the  edges  of  the  mucous  membrane  into  appo- 
sition with  one  another,  while  a  cicatrix  remains,  which  has  the  appearance 
of  a  large  number  of  agminated  warty  excrescences  of  the  mucous  mem- 
brane between  which  the  sero-fibrous  basis  from  which  they  proceed  may 
be  detected.  On  the  other  hand,  in  those  instances  of  the  disease  which 
have  been  distinguished  by  an  extensive  loss  of  substance,  the  approach 
of  the  edges  is  impossible,  and  the  deeper  layers  of  the  tissue  which  takes 
the  place  of  the  mucous  membrane  are  frequently  condensed  into  fibrous 
bands,  which  form  projections  into  the  intestinal  cavity,  interlaced  with 
one  another,  and  not  unfrequently  encroach  upon  the  calibre  of  the  intes- 
tine, in  the  form  of  valvular  or  annular  folds,  thus  giving  rise  to  a  variety 
of  stricture  of  the  colon. 

Reference  has  already  been  made  to  the  participation  by  the  liver  in 
disease  in  connection  with  Dysentery.  Abscess  of  the  liver  has  been 
supposed  by  some  authorities  to  have  an  intimate  relationship  to  the  dys- 
enteric process  in  the  colon.  Of  the  not  unfrequent  association  of  the 
two  diseases  there  can  at  all  events  be  no  question.  Dr.  Parkes'  found, 
in  twenty-five  cases  of  Dysentery,  seven  to  be  affected  with  hepatic  ab- 


'  Remarks  on  the  Dysentery  and  Hepatitis  oi  India,  1846. 


DYSENTERY.  101 

scess.  In  the  large  work  of  Mr.  Annesley,'  there  are  twenty-nine  cases 
of  abscess  of  the  liver  recorded,  and  of  these  no  fewer  than  twenty-one, 
or  nearly  three-fourths,  had  ulceration,  more  or  less  extensive,  in  the 
large  intestine,  while  in  two  other  cases  there  were  appearances  of  con- 
striction and  contraction  which  wore  reasonably  ascribed  to  the  existence 
of  Dysentery  at  some  former  period.  Annesley  regarded  the  Dysentery 
as  the  result  of  the  disease  of  the  liver,  or  hepatitis.  By  certain  writers, 
among  whom  Dr.  Abercrombie'  and  the  late  Dr.  William  Thomson  of 
Glasgow'  may  be  mentioned,  the  concurrence  of  the  two  diseases  has 
been  regarded  as  accidental.  The  former  observes:  "  Dysentery  is  often 
accompanied  by  diseases  of  neighboring  organs,  especially  the  liver,  in 
which  are  to  be  found,  in  some  cases  abscesses,  in  others,  where  pro- 
tracted in  their  duration,  chronic  induration.  These  are  to  be  regarded 
as  accidental  combinations,  though  they  may  considerably  modify  the 
symptoms."  A  third  view,  and  one  which  has  been  popular  in  this  coun- 
try since  it  was  ably  upheld  by  Dr.  Budd,*  is  that  the  inflammation  of 
the  liver  terminating  in  abscess  is  the  result  of  purulent  absorption  from 
the  dysenteric  process  in  the  colon.  Many  years  ago,  Andral  and  Louis, 
apparently  unsuspecting  any  connection  between  hepatic  abscess  and) 
ulcerated  intestines,  noticed  the  co-existence  of  the  former  with  ulcera- 
tion in  the  large  intestines  and  in  the  lower  end  of  the  ileum  in  two  cases, 
in  the  lower  end  of  the  ileum  alone  in  one  case,  in  the  stomach  in  four 
cases,  in  the  gall-bladder  in  one.  In  one  of  the  cases  in  which  the  stom- 
ach was  affected,  Andral  concludes  with  reason  that  the  ulcer  was  caused 
by  the  hepatic  abscess  bursting  into  the  stomach.  But  excluding  this 
observation,  there  resulted  seven  out  of  fifteen  instances  of  hepatic  ab- 
scess, in  which  there  existed  at  the  same  time  ulceration  in  some  part  of 
the  extensive  mucous  surface  which  returns  its  blood  to  the  portal  vein. 
These  observations  of  the  French  pathologists  were  very  far  indeed  from 
being  singular.  Thus  Dr.  Cheyne,  of  Dublin,  in  writing  of  the  Dysentery 
in  Ireland,  remarks  that  in  the  majority  of  his  dissections  the  liver  was 
apparently  normal,  but  that  in  two  cases  he  found  abscesses  in  its  sub- 
stance. But  while  the  occasional  intimate  connection  of  hepatic  abscess 
with  Dysentery,  and  of  which  Dr.  Budd's  theory  in  all  probability  assigns 
the  true  cause,  has  been  determined,  it  must  also  be  admitted  that  ab- 
scess of  the  liver  frequently  occurs  in  tropical  countries  wholly  uncon- 
nected with  Dysentery,  not  acknowledging  a  pyaemic  origin,  and  not  re- 
sulting from  mechanical  injury.  Dr.  Murchison,  of  London,  in  his  papers 
on  the  Climate  and  Diseases  of  Burmah,'  pointed  out  that,  in  many  cases, 
abscess  of  the  liver  met  with  in  tropical  countries  occurred  independently 
of  these  three  causes.  Dr.  Morehead,*  while  admitting  the  occasional  oc- 
currence of  hepatic  abscess,  according  to  Dr.  Budd's  explanations — that 
is,  by  the  transmission  to  the  liver  of  pus  or  vitiated  secretion  originating 
in  an  ulcerated  intestinal  surface, — is  satisfied  that,  as  a  general  proposi- 
tion, such  a  view  is  altogether  at  variance  with  tlie  results  of  clinical  re- 
search in  India.     Seventeen  cases  of  hepatic  abscess  are  detailed  by  Dr. 

'  Researches  into  the  Causes,  Nature,  and  Treatment  of  the  more  prevalent  Dis- 
eases of  India  and  of  Warm  Climates  generally.  By  James  Annesley,  2  vols.  4to. 
London,  1828. 

*  Researches  on  the  Pathology  of  the  Intestinal  Canal.     1820. 

^  Practical  Treatise  on  the  Diseases  of  the  Liver  and  Biliary  Passages.     1841. 

*  On  Diseases  of  the  Liver,  1845. 

*  Edinburgh  Med.  and  Surg.  Joum.  1854. 

*  Clinical  Researches  on  Diseases  in  India.     2  vols. 


102  DISEASES   OP  THE   INTESTTNIES   AND   PERirONEUM. 

Morehead  in  which  no  intestinal  ulceration  existed.  Frerichs,  moreover, 
is  of  the  same  opinion,  although  by  no  means  denying  that,  in  certain 
cases,  dysenteric  as  well  as  other  forms  of  ulceration  of  the  bowels  may 
originate  phlebitis  of  the  coats  of  the  portal  veins,  and  so  induce  hepatic 
abscess.'  The  abscess  of  the  liver  which  is  found  in  intimate  connection 
with  Dysentery  is  the  multiple  abscess,  small  but  numerous  collections  of 
pus.  This  form  of  purulent  deposition  Dr.  Murchison  has  very  distinctly 
shown  to  differ  from  the  ordinary  abscess  of  the  liver  which  occurs  in 
warm  climates.  In  the  latter  case  there  is  but  one  abscess  which  may 
attain  a  very  large  size,  or  in  a  few  instances  there  may  be  two  or  three 
collections.  Thus  the  pycemic  or  multiple  abscess,  which  is  the  common 
form  of  hepatic  suppuration  in  this  country,  is  to  be  distinguished  from 
the  tropical  abscess  of  India  and  other  hot  climates;  and  while  the  latter 
may  co-exist  with  Dysentery,  such  connection  is  wholly  accidental.  On 
the  other  hand,  the  multiple  hepatic  abscess,  although  by  no  means  of 
frequent  occurrence  in  India,  is  sometimes  met  with,  but  only,  as  Dr. 
Murchison  has  pointed  out,  in  connection  with  Dysentery  or  some  other 
source  of  purulent  absorption.  The  only  marked  instance  of  hepatic  ab- 
scess in  connection  with  dysentery  which  has  fallen  under  the  writer's 
immediate  observation  was  that  of  a  soldier  in  a  Highland  regiment,  who, 
while  serving  in  India,  became  affected  by  the  latter  disease,  which  ulti- 
mately assumed  a  chronic  and  inveterate  form.  He  was  ordered  home, 
and  during  his  voyage  to  England  the  liver  became  much  enlarged. 
Greatly  emaciated  and  reduced  in  strength,  and  still  suffering  from  fre- 
quent loose  stools,  he  sank  shortly  after  reaching  this  country.  Exami- 
nation of  the  body  after  death  revealed  the  existence  of  a  very  large 
number  of  small  abscesses  scattered  throughout  the  entire  substance  of 
the  liver,  the  tissue  of  which  was  in  different  parts  the  seat  of  consider- 
able induration. 

Etiology. — Neither  in  its  acute  nor  chronic  form  is  Dysentery  now 
a  common  disease  of  this  country.  The  decline  in  the  frequency  of 
its  occurrence  has  also  been  accompanied  by  a  diminution  in  the  sever- 
ity of  its  attacks.  From  producing  a  very  considerable  annual  mortality, 
as  was  the  case  in  the  seventeenth  century,  Dysentery  now  occupies  a  very 
low  place  among  the  causes  of  death.  Essentially  a  disease  of  hot  cli- 
mates, its  prevalence  is,  in  these,  observed  to  depend  to  a  considerable  ex- 
tent on  meteorological  changes,  while  in  temperate  climates  Dysentery  is 
emphatically  an  autumnal  malady.  The  continued  exposure  of  the  body 
to  an  elevated  temperature  predisposes  to  the  occurrence  of  Dysentery; 
this  it  does,  in  all  probability,  by  an  injurious  operation  on  the  mucous 
membrane  of  the  whole  alimentary  canal  leading  to  its  increased  excita- 
bility, and  by  disordering  the  function  of  the  liver:  thus  exposed,  the  sud- 
den reduction  of  temperature,  which  so  frequently  takes  place  in  the  night 
season  of  our  autumns,  acts  as  a  direct  exciting  cause  of  the  disease. 
Thus,  while  heat  predisposes  to  Dysentery,  cold  excites  it.  Unwholesome 
food  has  a  potent  action  in  the  production  of  Dysentery.  In  this  way  un- 
ripe fruits,  or  even  the  ripe  fruits  when  inordinately  consumed,  also  vege- 
tables, acid  wines,  and  impure  water,  have  particularly  been  supposed  to 
act.     There  can  indeed  be  no  doubt  that  most  of  the  slight,  and  some  even 

'  "  Eine  caoBale  Abhangigkeit  der  Hepatitis  von  Darmversch waning  ist  also  keines- 
wegs  festgestellt,  wenn  auch  die  Moglichkeit  nicht  gelaugnet  warden  darf,  dass  aus- 
nahmsweise  unter  begiinstigenden  Umstanden  dysenterische  und  andere  Darmver- 
Bchwarongen  Plilebitis  der  Pfortaderwurzeln  und  hierdurch  Leberabscesse  erzeugea 
konnen."— ^/i»t*  dLer  Leberkrankheiten,  Zweiter  Band,  p.  113. 


DYSENTERY.  103 

of  the  severer  cases  of  Dysentery  which  we  meet  with,  are  occasioned  by 
a  distinct  error  in  diet,  or  are  traceable  to  the  introduction  into  the  ah- 
mentary  canal  of  some  substance  or  fluid  of  a  deleterious  or  directly  irri- 
tating nature.  The  not  unfrequent  connection  of  Dysentery  with  ague, 
and  their  observed  alternation,  have  led  to  the  impression  that  the  former 
disease,  like  the  latter,  acknowledges  an  origin  in  malaria.  That  Dysen- 
tery may  be  produced  by  exhalations  from  putrid  animal  and  decaying 
vegetable  substances  may  perhaps  be  admitted;  but  the  probability  is 
that  the  relation  of  this  disease  to  intermittent  and  remittent  fevers, 
formerly  insisted  on,  was  not,  strictly  speaking,  etiological,  but  to  be  ac- 
counted for  by  the  disordered  state  of  the  portal  circulation,  which,  oc- 
curring in  ague,  led  indirectly  to  the  inflammatory  affection  of  the  colon. 
The  contagious  nature  of  Dysentery  has  been  asserted  by  some  authori- 
ties; facts  are,  however,  entirely  wanting  to  prove  the  communication  of 
the  disease  from  person  to  person,  in  the  sporadic  form  of  the  disease, 
with  the  consideration  of  which  we  are  occupied;  and  in  regard  to  the 
epidemic  Dysentery,  it  may  be  admitted  that  the  experience  which  ap- 
pears at  first  sight  to  justify  this  conclusion,  admits  of  another  and  moro 
satisfactory  explanation. 

Teeatment. — Dysentery  in  its  acute  form  demands  an  energetic  treat- 
ment; it  is  not  a  disease  which  can  with  safety  be  entrusted  to  the  "  vis 
naturae  medicatrix."  Confinement  to  bed  is  of  primary  importance,  the 
very  rest  favoring  the  arrestment  of  the  malady,  as  much  as  movement  of 
the  body  promotes  its  progress.  Blood-letting  was  formerly  practised  in 
the  treatment  of  Dysentery,  and  when  pain  is  severe,  and  continues  unre- 
lieved by  warm  applications  and  rubefacients,  local  blood-letting  by  means 
of  leeches  applied  over  the  track  of  the  colon  may  still  be  had  recourse  to. 
The  application  of  a  few  leeches  to  the  verge  of  the  anus  has  been  recom- 
mended by  some  authors,  and  in  the  experience  of  the  writer  has  ap- 
peared to  be  beneficial. 

An  indication  of  great  importance  in  the  treatment  of  Dysentery  is  to 
free  the  bowels  from  all  irritating  accumulations.  This  is  best  done  by 
the  employment  of  the  gentler  laxative  medicines.  Strong  cathartics  are 
not  to  be  used.  Castor-oil  has  been  almost  universally  regarded  as  the 
best  remedy  for  this  purpose.  Where  much  pain  exists  the  oil  may  from 
the  first  be  combined  with  a  little  laudanum;  in  the  more  advanced  stages 
of  the  disease  it  will  be  prudent  to  associate  the  latter  with  it  at  every 
dose.  The  alternation  of  laxatives  and  opiates  in  the  treatment  of  Dys- 
entery has  been  highly  praised  by  many  practitioners.  "  It  is  the  prac- 
tice of  some  physicians,"  writes  Sir  Thomas  Watson,  "  to  prescribe  laxa- 
tives and  opium  together;  but  in  this  complaint  it  is  better  to  alternate 
them."  '  Opium  by  not  a  few  has  been  regarded  as  the  "  summum  reme- 
dium"  in  this  disease.  It  was  the  favorite  remedy  of  Sydenham  in  meet- 
ing the  formidable  Dysentery  of  his  generation,  and  it  is  in  allusion  to 
its  efficacy  that  the  "  prince  of  English  practical  physicians  "  rapturously 
exclaims — "  And  here  I  cannot  but  break  out  in  praise  of  the  great 
God,  the  giver  of  all  good  things,  who  hath  granted  to  the  human  race, 
as  a  comfort  in  their  afflictions,  no  medicine  of  the  value  of  opium, 
either  in  regard  to  the  number  of  diseases  that  it  can  control,  or  its  effi- 
ciency  in    extirpating  them So    necessary  an   instrument    is 

opium  in  the  hands  of  a  skilful  man,  that  medicine  would  be  a  cripple 
without  it;  and  whoever  understands  it  well,  will  do  more  with  it  alone 

1  Lectures  on  the  Principles  and  Practice  of  Physic,  vol.  ii. 


104         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

than  he  could  well  hope  to  do  from  any  single  medicine.  To  know 
it  only  as  a  means  of  procuring  sleep,  or  of  allaying  pain,  or  of  check- 
ing a  diarrhoea,  is  to  know  it  only  by  halves.  Like  a  Delphic  sword  it 
can  be  used  for  many  purposes  besides.  Of  cordials  it  is  the  best  that 
has  hitherto  been  discovered  in  nature.  I  had  almost  said  it  was  the  only 
one."  '  Opium  may  be  administered  either  in  full  or  in  small  doses,  and 
each  of  these  methods  has  its  supporters.  It  may  be  given  alone,  or  com 
bined  with  ipecacuanha  in  the  form  of  Dover's  powder.  Ipecacuanha  it- 
self is  again  largely  employed,  and  more  especially  of  late  years  in  India. 
We  say  again  largely  employed,  for  it  is  worthy  of  remark  that  ipecacu- 
anha, originally  known  as  a  medicine  about  the  middle  of  the  seventeenth 
century,  was  first  used  as  a  remedy  in  Dysentery.  Brought  to  Europe 
from  Brazil  by  Piso,  and  some  time  afterwards  made  the  subject  of  exper- 
iment in  Paris  by  Adrien  Helvetius,  it  was  long  known  as  the  "  radix 
anti-dj'senterica,"  *  the  "pulvis  anti-dysentericus."  Subsequently  to  its 
original  employment  in  France,  in  doses  from  one  to  three  drachms,  it  was 
used  in  this  country  and  its  colonies  by  Sir  John  Pringle  and  other  phy- 
sicians, in  doses  varying  in  amount,  that  ordinarily  given  being  a  scruple. 
More  recently  the  names  of  Mr.  Mortimer,  Mr.  Twining,  Mr.  Docker,  and 
several  other  Indian  surgeons,  have  been  identified  with  the  practice  of 
exhibiting  ipecacuanha  in  Dysentery.  The  therapeutic  action  of  the 
remedy  has  been  variously  ascribed  to  its  nauseant,  its  diaphoretic,  and  its 
laxative  or  purgative  effects.  The  latter  was  the  view  entertained  by  the 
distinguished  writer  Sir  John  Pringle.  Dr.  Maclean  thus  expresses  him- 
self in  regard  to  it:  "It  is  probable  that  ipecacuanha  owes  much  of  its 
usefulness  in  this  disease  to  its  action  as  anevacuant.  It  is  a  blood  depu- 
rant  of  an  effective  kind.  It  appears  to  increase  the  secretion  of  the  whole 
alimentary  canal,  as  well  as  of  the  liver  and  pancreas:  under  its  use  tor- 
mina and  tenesmus  disappear,  and  feculent  evacuations  are  more  quickly 
restored  than  by  any  other  known  remedy."  '  Dr.  Morehead  has  always 
used  ipecacuanha  in  Dysentery  from  a  consideration  of  its  efficacy  being 
due  to  its  laxative  action.  This  physician  counsels  the  exhibition  of  the 
ipecacuanha  according  to  the  plan  of  the  late  Mr.  Twining,'*  viz.  "  from  six 
to  three  grains,  combined  with  blue  pill  from  five  to  two  grains,  and  ex- 
tract of  gentian  from  four  to  two  grains,  every  third,  fourth,  sixth,  or 
eighth  hour,  and  to  continue  it  steadily  till  amendment  takes  place.  The 
proportion  of  the  dose  and  the  frequency  of  its  repetition  must  depend  on 
the  acuteness  of  the  symptoms.  The  duration  of  the  treatment,  and  the 
gradual  diminution  of  the  dose  and  of  the  frequency  of  its  exhibition, 
must  be  contingent  on  the  rapidity  and  permanency  of  the  amendment. 
It  must  also  be  kept  distinctly  in  view  that,  whilst  the  treatment  by  ipe- 
cacuanha is  being  pursued,  it  is  often  necessary — according  as  the  state  of 
the  pulse  or  the  uneasiness  of  the  abdomen  on  pressure  may  indicate  the 
necessity — to  apply  leeches;  and  also — according  to  the  character  and 
scantiness  of  the  evacuations,  and  the  greater  or  less  fulness  of  the  abdo- 
men— to  give  castor-oil  occasionally  in  moderate  doses."  The  reliance  on 
the  therapeutic  action  of  ipecacuanha  is  most  conspicuously  exhibited, 
however,  in  the  plan  of  its  use  suggested  by  Mr.  Docker,  and  adopted  by 

'  Medical  ObservatioTiR  :  DyBentery. 

*  For  an  interesting  account  of  the  early  history  of  ipecacuanha,  Pee  "  Traits  Th6ra- 
pcntique  et  de  Matiere  Modicale,"  par  A.  TrousBeau  et  P.  Pidoux,  vol.  i.  p.  U(J6. 

*  Reynolds'  System  of  Medicine,  vol.  i.  article  Dysentery. 

*  Researches  on  Diseases  in  India,  vol.  i.  p.  500. 


DYSENTERY.  105 

Dr.  Maclean,"  and  now  generally  followed  in  India.  "The  patient  should 
be  at  once  ordered  to  bed,  and  as  quickly  as  possible  brought  under  the 
influence  of  ipecacuanha  in  large  doses.  Some  insist  on  the  propriety  of 
first  giving  a  full  dose  of  Battley's  sedative,  tincture  of  opium,  or  a  few 
drops  of  chloroform,  with  the  intention  of  making  the  stomach  tolerant  of 
the  remedy,  and  restraining  nausea  and  vomiting.  I  believe  that  the 
sedative  in  some  cases  is  useful,  and  acts  in  the  manner  just  described. 
On  the  other  hand,  I  have  often  seen  ipecacuanha  do  its  work  well,  and 
with  little  disturbance  of  the  stomach,  without  opium.  Should  it  be  de- 
termined to  premise  opium,  thirty  drops  of  the  tincture  should  be  given, 
and  in  half  an  hour  followed  by  from  twenty-five  to  thirty  grains  of  ipe- 
cacuanha, which  should  be  given  in  as  small  a  quantity  of  fluid  as  possi- 
ble; a  little  syrup  of  orange-peel  covers  the  taste  as  well  as  anything  else. 
As  already  advised,  the  patient  should  be  kept  perfectly  still,  and  abstain 
from  fluid  for  at  least  three  hours.  If  thirsty,  he  may  suck  a  little  ice,  or 
a  teaspoonful  of  cold  water  at  a  time  may  be  allowed.  It  is  seldom  that 
under  this  management  nausea  is  excessive,  and  vomiting  is  rarely  trouble- 
some, seldom  setting  in  for  at  least  two  hours  after  the  medicine  has  been 
taken.  The  abdomen  should  be  covered  with  a  large  sinapism,  or  a  sheet 
of  spongio-piline  sprinkled  with  a  little  turpentine  after  being  wrung  out 
of  hot  water.  In  from  eight  to  ten  hours,  according  to  the  urgency  of  the 
symptoms  and  the  effect  produced  by  the  first  dose,  ipecacuanha  in  a  re- 
duced dose  should  be  repeated,  with  the  same  precautions  as  before.  All 
who  have  had  opportunities  of  trying  this  mode  of  treating  Dysentery  can 
bear  testimony  to  the  surprising  efi:ects  that  often  follow  the  administra- 
tion of  one  or  two  doses  of  ipecacuanha  given  in  this  manner.  The  tor- 
mina and  tenesmus  subside,  the  motions  quickly  become  feculent,  blood 
and  slime  disappear,  and  often,  after  profuse  action  of  the  skin,  the  pa- 
tient falls  into  a  tranquil  sleep  and  awakens  refreshed.  The  treatment 
may  require  to  be  continued  for  some  days,  the  medicine  being  given  in 
diminished  doses,  care  being  taken  to  allow  a  sufficient  interval  to  admit 
of  the  patient  taking  some  mild  nourishment  suited  to  the  stage  of  the 
disease."  If  the  writer  be  entitled  to  express  an  opinion  regarding  the  use 
of  a  remedy  which  he  has  had  but  few  opportunities  of  employing  in  the 
treatment  of  Dysentery,  but  has  very  frequently  prescribed  in  cases  of  de- 
praved action  of  the  chylopoietic  viscera,  he  feels  inclined  to  ascribe  the 
eminent  therapeutic  virtues  of  ipecacuanha  to  its  direct  action  on  the  se- 
cerning function  of  the  liver. 

The  employment  of  mercury  in  Dysentery  is  as  warmly  defended  by 
some  practitioners  as  it  is  condemned  by  others.  In  all  stages  and  forms 
of  the  disease  Dr.  Maclean  deprecates  its  use,  while  Dr.  Wood  asserts  that 
no  remedial  influence  is  more  effectual  in  Dysentery  than  that  of  mercury. 
Anything  like  the  production  of  profuse  salivation  is  certainly  to  be 
avoided;  and  although  favorably  influencing  the  progress  of  Dysentery 
in  some  cases,  chiefly  through  its  action  on  the  liver,  it  will  generally  be 
admitted  that  in  ipecacuanha,  and  in  the  employment  of  mild  laxatives 
alternately  with  opiates,  we  possess  more  efficacious  and  certainly  safer 
remedies. 

It  is  in  the  more  chronic  form  of  Dysentery  that  such  powerful  astrin- 
gents as  acetate  of  lead,  sulphate  of  copper,  sulphate  of  zinc,  the  Indian 
Bael  fruit,  haematoxylon,  and  the  sulphuric  acid,  are  chiefly  useful. 

Among  alterative  remedies  copaiba  and  turpentine,  creasote  and  nux 

*  Reynolds'  System  of  Medicine,  vol.  i.  p.  120. 


106  DISEASES   OP  THE   ENTESTUTES   AND   PERITONEUM. 

vomica,  have  been  commended.  Quinine  will  favorably  influence  the  prog- 
ress of  malarial  Dysentery,  when  employed  as  an  adjunct  to  other  reme- 
dies; and  iron,  in  the  form  of  the  pernitrate  more  especially,  is  called  for 
when  fluidity  of  blood  as  evidenced  by  haemorrhages  and  cutaneous  pete- 
chiae  exist;  just  as  in  scorbutic  Dysentery,  when  chronic,  milk  and  fresh 
fruits  are  indispensable  articles  of  treatment. 

Enemata  of  warm  water  cautiously  introduced  into  the  rectum  are  fre- 
quently grateful  to  the  patient,  and  are  useful  in  the  early  stages  of  Dys- 
entery in  bringing  away  hardened  scybalous  masses,  the  continuance  of 
which  in  the  bowels  is  attended  by  much  irritation  and  suffering.  Opiate 
enemata,  and  those  containing  ipecacuanha,  and  various  astringents,  may 
sometimes  be  employed  with  good  effects.  In  Dysentery  assuming  a 
typhoid  or  adynamic  type,  it  is  necessary  to  support  the  patient's  strength 
by  the  exhibition  of  stimulants;  but  these  are,  as  a  general  rule,  not  well 
borne  in  this  disease,  and  should  always  be  administered  with  the  greatest 
degree  of  caution. 

The  diet  in  Dysentery  is  of  much  importance.  When  the  disease  is 
comparatively  slight  and  unattended  by  serious  febrile  symptoms,  most 
farinaceous  foods  may  be  allowed.  When,  however,  the  severer  form  of 
the  disease  is  in  existence,  bland  drinks  are  alone  admissible:  milk  with 
lime  water,  or  Carrara  water,  may  be  regarded  as  the  chief  article  of  diet, 
and  generally  speaking  is  the  one  most  relished  by  the  patient. 

Great  attention  should  be  paid  to  preserving  the  cleanliness  of  the 
patient,  the  dress,  and  bed-clothes,  and  in  keeping  the  atmosphere  of  the 
sick-room  as  pure  as  possible,  impregnated  as  it  must  from  time  to  time 
become  with  the  offensive  odor  of  the  discharges.  The  use  of  Condy's 
fluid,  of  weak  chlorine  vapor,  or  of  carbolic  acid  for  this  purpose,  is  inval- 
uable. 

Sponging  the  surface  of  the  body  with  tepid  or  warm  water  is  desira- 
ble, and  is  usually  found  most  grateful  by  the  patient. 

It  may  be  added  in  connection  with  the  treatment  of  chronic  Dysen- 
tery, that  change  of  air  is  frequently  more  efficacious  than  the  use  of 
drugs.  Removal  to  the  sea-coast,  or  a  voyage,  is  specially  to  be  recom- 
mended. 

A  flannel  belt  round  the  abdomen  is  an  article  of  clothing  which  the 
convalescent  from  Dysentery,  as  well  as  all  those  who  are  prone  to  suffer 
from  this  disease,  should  adopt  and  constantly  wear. 


DUODENUM. 

By   S.   O.  Habebshon,  M.D. 


The  symptoms  which  have  been  regarded  by  some  writers  as  proceed- 
ing from  disease  of  the  duodenum  have  by  others  been  referred  to  states 
of  the  liver,  of  the  stomach,  or  of  the  pancreas. 

My  own  observations,  and  the  facts  which  I  adduce  in  the  following 
remarks,  show  that  there  are  symptoms  of  disease  justly  attributable  to 
this  portion  of  the  alimentary  canal;  and  that  in  some  cases  we  may,  with 
care,  satisfactorily  diagnose  that  the  duodenum  is  diseased.  The  pecu- 
liarities of  its  position  and  structure  deserve  our  careful  attention.  Ex- 
tending from  the  pyloric  extremity  of  the  stomach  to  the  jejunum,  it  is 
about  twelve  inches  in  length,  and  may  be  divided  into  three  nearly  equal 
portions;  the  first  is  the  most  movable,  is  almost  surrounded  by  perito- 
neum, and  is  horizontal  in  its  direction;  it  may  be  called  the  pyloric  or 
stomachic  portion  of  the  duodenum,  for  it  is  associated  with  the  stomach 
in  its  diseases.  The  second  is  vertical  in  direction,  closely  fixed  near  to 
the  crura  of  the  diaphragm,  and  to  the  vena  cava;  it  receives  the  common 
bile  and  pancreatic  ducts  generally  by  a  single  opening,  and  is  hepatic  in 
its  morbid  relations.  The  pancreas  is  situated  on  the  left  side  of  the  sec- 
ond portion;  and  the  vena  portse,  the  hepatic  artery,  and  the  branches  of 
the  pancreatico-duodenal  artery  are  also  in  relation  with  it.  The  third  is 
horizontal  in  direction,  and  is  simply  intestinal  in  its  function;  the  pan- 
creas is  situated  above  it;  in  front  the  superior  mesenteric  vessels  enter 
the  mesentery,  and  behind  it  are  placed  the  aorta  and  the  vena  cava. 
The  three  portions  of  the  duodenum  are  situated  on  different  planes,  the 
first  portion  being  near  to  the  anterior  abdominal  parietes,  whilst  the 
third  part  is  immediately  upon  the  spine;  and  this  arrangement  allows 
the  contents  of  the  canal  mechanically  to  gravitate  quickly  into  the  je- 
junum, and  assists  also  the  discharge  of  bile  from  the  ducts. 

The  muscular  layers  of  the  duodenum  are  double;  a  circular  and  a 
longitudinal  coat,  as  in  other  portions  of  the  small  intestine.  The  mu- 
cous coat  is  covered  with  villi,  which  commence  at  the  duodenum,  and 
soon  become  exceedingly  numerous;  so  also  the  valvulae  conniventes  are 
gradually  developed,  till  we  find  them  as  large  as  in  the  jejunum.  The 
whole  of  the  surface  is  studded  over  with  Lieberktlhn's  follicles;  not  un- 
frequently,  especially  in  young  subjects,  there  are  solitary  glands,  as  in 
the  jejunum  and  ileum.  There  are  also  the  glands  of  Brunner,  minute 
compound  glands  peculiar  to  the  duodenum,  and  which  are  situated  be- 
neath the  substance  of  the  mucous  membrane;  these  commence  a  few 
lines  from  the  pylorus,  and  extend  about  as  far  as  the  common  bile-duct; 
their  function  is  not  definitely  known,  but  they  are  believed  to  resemble 
minute  salivary  or  pancreatic  glands.     It  sometimes  happens  that  the  soli- 


108  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

tary  g^lands  are  so  distinct  that  they  may  very  easily  be  mistaken  for 
Brunner's  glands;  the  latter  are,  however,  situated  beneath  the  mucous 
membrane,  and  microscopical  examination  at  once  manifests  their  differ- 
ence. 

There  is  still  another  point  in  connection  with  the  duodenum  that 
deserves  consideration,  and  which  indicates  its  close  connection  with  the 
stomach  and  with  the  liver.  The  pneumogastric  nerves,  branches  of 
which  supply  the  stomach,  and  also  the  liver,  send  filaments  along  the 
first  portion  of  the  duodenum,  continued  onwards  from  the  lesser  curva- 
ture of  the  stomach;  this  associates  that  part  of  the  duodenum  very  inti- 
mately with  the  stomach.  Besides  this  nervous  supply  we  have,  according 
to  the  observations  of  Meissner  and  Auerbach,  minute  plexuses  of  nerves 
both  in  connection  with  the  mucous  and  muscular  coats. 

The  pancreatico-duodenal  artery,  which  supplies  the  greater  part  of 
the  duodenum,  is  from  the  hepatic,  and  the  pyloric  branch  of  the  coro- 
nary extends  into  the  first  part  of  the  duodenum,  so  that  in  the  arterial 
supply  we  find  the  same  association. 

iState  of  secretion. — The  secretion  is  stated  to  be  alkaline,  and  such  is 
probably  the  case;  the  acid  reaction  after  death  arising  from  the  gastric 
juice,  which  has  gravitated  through  the  pylorus.  Whether  a  patulous, 
feeble  contractile  power  in  the  pylorus,  allowing  the  secretions  of  the 
stomach  to  pass  at  irregular  periods  into  the  duodenum,  is  the  cause  of 
the  discomforts  associated  with  these  forms  of  dyspepsia,  we  have  no  data 
on  which  to  form  an  opinion.  Corvisart  states  that  the  pancreatic  fluid 
discharged  into  the  duodenum  has  the  power  of  dissolving  albuminous 
substances;  this  opinion  is,  however,  controverted  by  Dr.  Brinton;  the 
former  describes  duodenal  dyspepsia  as  arising  from  an  abnormal  condi- 
tion of  this  secretion. 

Congenital  malformation. — The  duodenum  sometimes  has  a  double 
sigmoid  curvature — a  peculiar  arrangement  which  I  observed  in  a  patient 
who  died  from  intestinal  obstruction.  The  ascending  colon  was  adherent 
to  the  sigmoid  flexure,  and  the  caecum,  twisted  upon  itself,  was  situated 
in  the  left  hypochondriac  region.  The  person  had  been  born  at  the  sev- 
enth month,  and  the  caecum  was  preternaturally  free. 

In  a  Cyclopean  monster,  I  found  the  viscera  of  a  double  foetus  in  a 
single  peritoneal  cavity;  a  double  oesophagus  was  united  in  a  single  stom- 
ach, with  a  large  convexity  extending  across  the  abdomen;  and  a  single 
duodenum,  placed  vertically,  received  the  biliary  pancreatic  ducts  on 
either  side. 

Diverticula  are  exceedingly  rare  as  compared  with  those  which  arise 
from  the  lower  part  of  the  ileum;  but  small  pouches  are  more  frequently 
present,  and  they  consist  generally  of  mucous  membrane,  thus  constitu- 
ting a  sort  of  hernial  protrusion.  In  the  museum  of  Guy's  is  one  of  these, 
situated  near  the  opening  of  the  duct  into  the  duodenum. 

Some  believe  that  the  duodenum  becomes  distended  with  flatus,  or 
with  retained  chyme,  as  the  result  of  indigestion;  and  where  there  is 
mechanical  obstruction,  which  we  shall  afterwards  describe,  this  may  be 
the  case.  It  is  possible  also  that  an  enormously  distended  transverse 
colon  may  impede  the  free  passage  of  the  contents  of  the  third  portion, 
but  such  is  problematical.  The  distention  which  has  been  supposed  to 
arise  from  the  duodenum  will  generally  be  found  to  be  distention  of 
the  stomach  or  the  transverse  colon;  for  the  duodenum  passes  quickly 
to  a  lower  level,  and  I  believe  its  contents  at  once  gravitate  into  the 
jejunum. 


DUODENUM.  109 

As  to  the  strictly  pathological  states,  we  find  congestion  sometimes 
active,  more  frequently  passive;  ulceration,  cancer,  and  lastly  mechanical 
obstruction  are  also  noticed. 

To  some  it  may  appear  altogether  futile  to  speak  of  congestion  or 
hyperaemia  of  the  duodenum,  but  observation  of  the  appearances  after 
death  convinces  me  that  marked  changes  occur,  and  that  in  some  in- 
stances a  careful  investigation  might  have  pointed  out  their  existence 
during  life. 

Great  congestion  of  the  duodenum  is  found  in  various  diseases  in 
which  a  similar  condition  extends  to  the  whole  tract  of  the  alimenLiry 
canal,  as  in  disease  of  the  mitral  valve,  and  in  portal  obstruction  in  he- 
patic disease;  but  there  are  other  cases  in  which  we  find  active  congestion, 
especially  in  acute  pneumonia.  The  latter  state  of  acute  hyperaemia  is 
illustrated  in  the  following  case: 

Case  LXXXV. — Inflammation  of  the  Bronchi,  of  the  Bile-ducts,  or 
Biliary  Hepatitis,  &c.     Acute  Congestion  of  the  Duodenum. — Thomas 

H ,  jet.  43,  was  admitted  into  Guy's  Hospital  March,  1852;  he  had  been 

ill  for  three  weeks.  He  was  a  large,  stout  man,  who  for  fourteen  years 
had  been  in  the  police  service;  his  habits  of  life  had  been  very  intemper- 
ate. Four  years  previously  he  had  received  a  severe  blow  in  his  right 
side  from  a  prize-fighter,  and  for  some  time  he  had  been  subject  to  vom- 
iting in  the  morning,  and  the  bowels  had  at  times  been  much  relaxed;  be- 
fore admission  jaundice  came  on;  he  had  had  more  anxiety  of  mind  than 
usual,  and  gradually  became  languid  and  icteric.  For  four  days  his  legs 
"had  swollen,  afterwards  his  abdomen,  and  his  strength  became  prostrated. 
The  skin  was  of  a  dusky  yellow  color;  the  tongue  was  dry,  brown,  and 
furred;  respiration  44;  the  pulse  100,  soft  and  compressible;  the  abdomen 
was  much  distended  with  flatus,  and  fluctuation  could  also  be  felt;  the 
liver  extended  several  inches  below  the  ribs,  and  there  was  tenderness  on 
pressure  in  that  part.  In  the  chest  there  were  general  bronchial  rales;  he 
was  delirious  at  night,  and  slept  but  little;  the  motions  were  light  in 
color,  the  bowels  relaxed,  the  urine  contained  lithates  and  the  coloring 
matter  of  bile.  Three  days  after  admission  he  was  more  prostrate,  and 
was  delirious;  the  pulse  was  very  compressible;  he  had  pain  in  the  right 
hypogastric  region,  and  on  the  following  day  he  died. 

On  inspection  severe  capillary  bronchitis  was  found;  the  larger  bronchi 
were  also  diseased;  they  were  somewhat  congested, and  contained  yellow- 
colored  tenacious  mucus.  The  heart  was  large,  and  had  around  it  a  con- 
siderable quantity  of  fat;  the  right  ventricle  was  thin;  the  left  ventricle 
had  undergone  partial  fatty  degeneration.  The  valves  were  healthy,  with 
the  exception  of  slight  thickening  of  the  mitral.  Abdomen. — There  were 
several  pints  of  yellow  serum  in  the  peritoneum;  the  intestines  were  con- 
siderably distended  with  flatus,  and  the  liver  extended  several  inches  be- 
low the  ribs.  The  duodenum  contained  Moody  mucus,  the  lining  mem- 
brane  was  very  mu^h  congested,  and  in  some  parts  ecchymosed.  The 
lower  part  of  the  small  intestine  contained  clayey  faeces.  There  was  a 
considerable  quantity  of  fat  in  the  omentum,  and  in  the  abdominal  pa- 
rietes. 

The  liver  weighed  7  lbs.;  its  surface  was  smooth,  and  of  a  deep  green- 
ish-yellow color,  and  some  veins  were  seen  upon  it;  the  acini  were  whitish 
in  color.  The  section  of  the  liver  appeared  coarse  along  the  smaller 
branches  of  the  vena  portas;  the  capillary  vessels  in  Glisson's  capsule 
were  much  distended,  and  some  of  them  were  quite  turgid  with  blood. 


110         DISEASES    OF   THE   INTESTINES   AND   PERITONEUM. 

The  smaller  biliary  vessels  contained  tenacious  mucus,  and  their  lining 
membrane  was  congested;  this  state  of  the  bile-ducts  contrasted  remark- 
ably with  the  pale  color  of  the  veins.  The  cells  of  the  liver  were  gorged 
with  fat,  some  of  them  were  distended  with  oil-globules;  other  hepatic 
cells  appeared  ruptured,  and  granules  with  oil-globues  were  dispersed 
upon  the  field  of  the  microscope.  The  deep  green  spots  did  not  present 
any  cells,  but  only  granular  matter. 

The  larger  bile-ducts  were  free,  but  the  opening  into  the  duodenum 
was  very  much  congested;  the  gall-bladder  was  empty;  the  kidneys  were 
large  and  congested;  the  spleen  was  firm,  and  contained  several  fibrinous 


The  health  of  this  man  was  much  impaired  by  his  intemperate  habits, 
and  his  liver  had  probably  been  diseased  for  a  considerable  period.  The 
affection  of  the  chest  came  on  subsequent  to  his  admission  into  the  hospi- 
tal, and  consequently  after  the  jaundice.  There  was  evidently  acute 
disease  of  the  smaller  biliary  tubes,  as  indicated  by  the  congestion  of 
Glisson's  capsule,  by  the  congestion  of  the  lining  membrane  of  the  biliary 
tubes,  and  the  tenacious  mucus  they  contained;  the  hepatic  structure  was 
stained  with  bile.  The  bronchitis  which  subsequently  took  place  was, 
perhaps,  the  cause  of  the  fatal  termination,  and  tended,  doubtless,  to  in- 
crease the  congestion  of  the  mucous  membrane.  The  very  congested 
state  of  the  duodenum  near  the  entrance  of  the  bile-ducts  indicated  an  ex- 
tension of  disease  from  the  duodenum  to  the  bile-ducts,  or  vice  versd  /  it 
was  much  more  localized  than  is  observed  in  the  secondary  congestion  of 
the  mucous  membrane  in  pulmonary  obstruction.  This  did  not  appear  to 
be  an  affection  in  which  much  benefit  could  be  obtained  from  the  adminis- 
tration of  mercury,  but  rather  from  salines  with  sedatives. 

After  bums  the  mucous  membrane  of  the  duodenum  has  been  found 
greatly  congested,  and  in  several  cases  recorded  by  Mr.  Curling  in  the 
*  Medico-Chirurgical  Transactions '  this  part  of  the  intestine  was  ulcerated. 
This  statement  has  not  been  confirmed  by  the  observations  of  Dr.  Wilks, 
recorded  in  the  'Guy's  Reports'  for  1856.  I  witnessed  many  of  the  cases 
to  which  he  refers;  and  although  in  some  the  first  part  of  the  duodenum 
was  hypereemic,  in  none  did  I  observe  ulceration.  A  case  of  ulceration 
of  the  duodenum  after  a  burn  has,  however,  been  placed  in  the  Museum 
at  Guy's,  by  Sir  Wm.  Gull.  The  child  survived  twenty-five  days,  but 
died  comatose;  a  small  cicatrizing  ulcer  was  found  in  the  first  part  of  the 
duodenum. 

Since  the  former  edition  of  this  work  was  written  three  cases  of  ulcer 
of  the  duodenum  after  burns  have  occurred  at  Guy's. 

In  one  the  patient  was  admitted  for  an  extensive  scald,  and  died  thir- 
teen days  after  admission.  The  duodenum  contained  two  small  ulcers, 
one  the  size  of  a  pea,  the  other  of  a  hemp-seed,  and  Brunner's  glands  were 
swollen.  The  ulcers  appear  to  have  had  nothing  to  do  with  the  man's 
death. 

The  second,  a  male  child,  set.  4,  died  nineteen  days  after  a  severe  burn 
of  the  lower  extremities.  He  was  doing  well,  and  the  bum  was  healing, 
when  three  days  before  death  he  began  to  pass  blood  into  the  bed.  A 
large  ulcer  was  found  in  the  duodenum,  and  the  pancreatico-duodenal 
artery  was  opened.  The  child  had  also  two  small  ulcers  on  its  tongue, 
extending  through  the  mucous  membrane. 

Tlie  last  case  occurred  in  a  girl,  aet.  13,  who  died  from  tetanus  about 
thirteen  days  after  an  extensive  bum.     The  stomach  was  ecchymosed, 


DUODENUM.  Ill 

and  immediately  beyondT  the  pylorus  was  a  small  ulcer  with  thick  raised 
edges.  The  thickening  was  considerable,  so  as  to  cause  a  suspicion  that 
the  ulcer  antedated  the  burn.     There  was  irregular  injection  around  it. 

The  pathology  of  such  cases  is  still  involved  in  much  obscurity.  Em- 
bolism and  necrosis  of  tissue  from  blood  extravasation  after  congestion 
have  been  suggested,  as  we  have  already  mentioned,  in  stating  the  hy- 
pothetical explanations  of  acute  perforating  ulcer  of  the  stomach. 

Mr.  Curling  describes  diarrhoea,  and  the  discharge  of  blood,  as  having 
arisen  from  this  condition  of  the  duodenum,  and  sometimes  severe  haema- 
temesis  and  prostration.  In  some  instances  death  took  place  from  peri- 
tonitis consequent  on  perforation.  After  such  severe  injury  to  the  skin^ 
it  is  not  surprising  to  find  great  disturbance  of  the  circulation  or  of  the 
internal  organs,  and  especially  of  the  mucous  membranes,  which  are  known 
to  sympathize  so  closely  with  the  skin;  in  some  of  these  cases  stimulants 
appear  to  have  been  administered  freely,  and  these  have  probably  con- 
duced to  this  diseased  appearance  of  the  duodenum. 

Chronic  congestion  produces  gray  discoloration  of  the  mucous  mem- 
brane; and  in  the  examination  of  the  discolored  part  we  find  that  the 
deep  color  is  produced  by  the  deposit  of  irregular  grains  of  pigment,  very 
thickly  placed  in  the  substance  of  the  mucous  membrane,  near  to  its  upper 
surface,  and  probably  in  the  coats  of  the  capillaries;  the  apparent  explana- 
tion of  this  state  being,  that  gastro-enteritis,  or  long-continued  hyperaemia, 
has  been  followed  by  the  deposition  of  haematine  or  pigment  in  the  sub- 
stance of  the  membrane. 

In  several  cases  of  this  gray  discoloration  the  appearance,  both  in 
children  and  in  adults,  has  been  uniform.  A  child,  aet.  9,  a  thin,  poorly 
nourished,  pale  boy,  who  had  been  subject  for  some  time  to  looseness  of 
bowels,  whilst  running,  hurt  his  thigh;  he  shortly  afterwards  complained 
of  pain  at  that  part;  he  was  admitted  into  Guy's  in  a  typhoid  state,  and 
died  two  days  afterwards.  There  was  suppuration  in  the  brain,  and  gray 
discoloration  of  the  mucous  membrane  of  nearly  the  whole  of  the  small 
and  large  intestines. 

Chronic  congestion  is  observed,  as  before  stated,  in  connection  with 
pulmonary  and  hepatic  congestion,  in  fact,  in  any  disease  which  leads  to 
distention  of  the  vena  portas;  and  we  also  find  a  less  general  condition 
of  congestion  of  the  first  part  of  the  duodenum  in  disease  of  the  pylorus, 
whether  it  be  simple  fibroid  degeneration  and  hypertrophy,  or  true  can- 
cerous disease.  The  mucous  membrane  becomes  thickened,  its  vessels 
congested,  and  its  glands  enlarged;  sometimes,  indeed,  so  much  so  that 
the  glands  might  easily  be  mistaken  for  minute  cancerous  tubercles.  The 
continued  irritation  thus  leads  to  hypertrophy  of  the  glands  of  the  mucous 
membrane,  as  we  find  in  other  similar  structures. 

The  duodenum  is  sometimes  found,  after  death,  to  be  filled  with  blood, 
and  a  coagulum  is  occasionally  moulded  into  its  exact  form.  This  is  due 
to  extravasation  of  blood  from  ulceration  and  perforation  of  an  artery,  in 
the  duodenum  or  in  the  stomach. 

As  to  the  symptoms  arising  from  the  conditions  just  described,  they 
appear  to  be  so  continually  bound  together  with  those  indicative  of  sim- 
ple disease  of  the  contiguous  viscera,  that  definiteness  and  certainty  can- 
not be  attained.  The  vomiting  and  pain  connected  with  hepatic  disease 
and  gall-stone  are  possibly  due  partly  to  the  condition  of  the  duodenum. 
In  the  latter  there  is  probably  spasmodic  contraction  of  the  canal;  but  of 
this  we  do  not  speak  with  certainty.  In  the  cases  described  by  Mr. 
Curling,  vomiting  was  a  frequent  symptom;  and  the  bilious  evacuation 


112         DISEASES   OP  THE  INTESTINES   AND   PERITONEUM. 

in  violent  vomiting  indicates  that  the  first  and  second  portions  of  the 
duodenum  have  been  involved. 

Instances  are  not  unfrequently  met  with  in  which,  several  hours  after 
food,  there  is  pain  at  the  region  of  the  duodenum,  perhaps  with  violent 
vomiting,  faintness,  pallor  of  the  countenance;  and  these  symptoms  have 
by  some  persons  been  referred  to  the  duodenum,  as  a  form  of  duodenal 
dijcpepsia  or  inflammation ,'  by  others  to  the  pyloric  valve;  but  occasion- 
ally jaundice  follows,  which  appears  to  strengthen  the  former  supposition. 
After  intemperance,  also,  violent  bilious  vomiting,  a  furred  state  of  the 
tono-ue,  loss  of  appetite  and  loathing  of  food,  diarrhoea,  tenderness  of  the 
right  hvpochondriac  region,  are  followed  by  jaundice;  and  we  are  prone 
to  regard  the  duodenum  as  being  in,  at  least,  a  state  of  great  hyperaemia. 
Exposure  to  cold,  with  great  mental  anxiety,  tends  also  to  promote  this 
state  of  duodenal  disease;  and  the  mischief  appears  to  be  propagated  to 
the  bile-ducts.  Sir  H.  Marsh  has  drawn  attention  to  the  occurrence  of 
jaundice  with  disease  of  the  duodenum,  in  the  '  Dublin  Medical  and  Sur- 
gical Journal ; '  see  also  Dr.  Stokes,  in  the  '  Encyclopjedia  of  Practical 
Medicine.' 

Congestion  of  the  duodenum  is  best  relieved  by  diminishing  portal 
and  hepatic  engorgement,  and  by  stimulating  the  abdominal  excretory 
organs  to  increased  action.  These  objects  may  be  attained  by  giving 
saline  and  mercurial  purgatives,  by  aperient  enemata,  and  by  the  appli- 
cation of  leeches  to  the  anus  or  to  the  scrobiculus  cordis.  A  free  dose  of 
calomel,  blue  pill,  or  gray  powder,  followed  by  a  saline  aperient  draught, 
often  acts  very  effectively  as  a  purgative;  but  in  many  instances,  espe- 
cially where  the  morbid  condition  arises  from  chronic  pulmonary  disease  or 
obstructive  disease  of  the  heart,  small  doses  of  mercurials  may  be  very 
advantageously  combined  with  squills  and  foxglove,  so  as  thoroughly  to 
act  on  the  abdominal  excretory  glands;  but  to  give  mercury  so  as  to  pro- 
duce salivation,  or  to  prescribe  it  in  every  instance  where  bilious  fluid  is 
rejected,  appears  to  be  an  unwise  course.  The  most  bland  nourishment 
should  be  given,  and  abstinence  from  stimulants  should  be  enjoined;  ice 
and  cold  drinks  often  afford  great  relief  when  vomiting  distresses  the 
patient.  In  acute  hyperremic  states,  salines,  as  the  solution  of  potash, 
the  bicarbonates  of  potash  or  soda,  the  carbonates  or  the  citrate  of  mag- 
nesia, may  be  given  with  diuretics  in  effervescence  or  otherwise,  as  the 
individual  case  may  require.  But  in  chronic  hyperaemia,  where  there  is 
profuse  secretion  of  mucus,  more  advantage  will  be  found  from  the  dilute 
nitric  or  nitro-hydrochloric  acids,  with  laxatives,  as  taraxacum,  or  with 
cinchona,  and  from  the  old  compound  gentian  mixture  of  the  Loudon 
Pharmacopoeia. 

The  most  acute  form  of  inflammation  is  sometimes  observed  after  the 
administration  of  poisons.  In  a  case  of  poisoning  by  sulphuric  acid, 
where  several  square  inches  of  the  mucous  membrane  of  the  stomach  had 
been  destroyed,  the  duodenum  was  found  intensely  congested,  and  cover- 
ed throughout  by  a  thin,  adherent,  diphtheritic  membrane.  In  this 
case  the  vomiting  and  dysphagia  disappeared  on  the  third  day,  and  the 
patient,  though  extremely  prostrate,  did  not  appear  to  suffer  much  from 
pain.  Arrowroot,  lime-water,  and  milk,  &c.,  were  administered,  and  for 
a  week  it  was  thought  that  the  patient  might  rally.  (See  "  Diseases  of 
Stomach.")  In  ordinary  practice,  however,  we  do  not  meet  with  this 
form  of  disease. 

Ulceration  of  the  duodenum  varies  both  in  degree  and  extent;  some- 
times it  is  merely  superficial,  and  is  associated  with   other  diseases,  as 


DUODENUM.  113 

in  a  patient  who  died  from  albuminuria  with  pericarditis,  in  whom  the 
duodenum  presented  superficial  ulceration,  the  result  of  erythematous 
or  acute  inflammation;  or  there  may  be  chronic  ulcer,  resembling  that 
found  in  the  stomach,  and  presenting  many  symptoms  in  common  with 
that  disease. 

Some  duodenal  ulcers  have  raised  and  thickened  edges,  with  depressed 
centres,  being  evidently  of  slow  formation.  They  are  mostly  found  in  the 
first  portion  of  the  duodenum;  and  since  this  part  of  the  intestine  is  al- 
most surrounded  by  the  peritoneum,  we  sometimes  have  fatal  peritonitis, 
produced  by  perforation,  as  in  the  stomach,  the  muscular  and  peritoneal 
coats  being  also  destroyed  by  the  ulcer;  or  adhesion  takes  place  with  the 
adjoining  structures,  as  the  liver  and  pancreas,  &c.  ;  and  these  oftentimes 
constitute  the  floor  of  the  ulcer. 

Several  cases  have  come  under  my  own  notice  the  early  symptoms  of 
which  were  exceedingly  slight,  till  sudden  and  fatal  peritonitis  had  been 
set  up  by  perforation.  In  some  instances  these  ulcers  have  been  associated 
with  violent  vomiting,  the  persistence  and  aggravation  of  which  were  at- 
tributed to  this  diseased  condition;  this  occurred  in  a  young  woman,  aged 
twenty-four,  who  was  admitted  into  Guy's  Hospital  with  very  urgent 
vomiting;  the  pulse  was  small  and  frequent;  she  was  pregnant,  and  died 
in  a  short  time  from  peritonitis;  a  small  ulcer  was  found  in  the  duodenum.' 
The  vomiting  was  probably  referred  to  sympathetic  irritation  from  the 
uterine  state;  and  a  favorable  prognosis  would  in  many  such  cases  have 
been  given  till  the  symptoms  of  peritonitis  came  on. 

The  second  portion  of  the  duodenum  is,  however,  also  liable  to  ulcer- 
ation, as  in  a  case  preserved  in  the  museum  of  Guy's,  where  the  coats  of 
the  whole  of  the  vertical  portion  on  the  pancreatic  side  were  destroyed,, 
and  the  pancreas  formed  the  base  of  a  large  chronic  ulcer,  in  the  centre- 
of  which  was  seen  the  opening  of  the  biliary  and  pancreatic  duct.  There- 
was  a  small  ulcer  in  the  third  portion  of  the  duodenum;  and  peritonitis, 
had  been  set  up;  the  pancreas  was  enlarged.  The  patient  was  forty-fou-r 
years  of  age,  and  had  empyema;  he  became  exceedingly  emaciated  bef ore- 
death,  and  suffered  from  vomiting  as  well  as  from  melfena. 

Ulceration  is  sometimes  followed  by  constriction;  and  adhesions  also 
frequently  form  between  the  first  part  of  the  duodenum  and  the  gall- 
bladder; in  some,  ulceration  extends  ^rom  the  gall-bladder  into  the  duo- 
denum, thus  allowing  the  passage  of  calculi;  and  the  gall-bladder  is,  ia 
other  cases,  entirely  obliterated. 

Pain  several  hours  after  food,  a  sallow  complexion,  furred  tongue,, 
feebleness  of  circulation,  mental  depression,  nausea,  and  irritable  bowels^, 
have  been  ascribed  to  ulceration  of  the  duodenum,  but  the  facts  do  not 
fully  warrant  this  conclusion.  In  the  several  instances  we  have  observed 
there  were  no  such  indications;  in  some,  the  ulceration  was  associated 
with  disease  of  the  gall-bladder;  in  others,  with  chronic  disease  of  the 
liver;  and  the  predisposing  and  exciting  cause  of  the  hepatic  disturbance 
had  probably  induced  the  duodenal  mischief. 

Ulceration  of  the  duodenum  must  be  remembered  both  as  a  source  of 
fatal  perforation  and  of  intestinal  haemorrhage,  as  well  as  of  haemate- 
mesis. 

The  treatment  of  these  cases  is  similar  in  all  respects  to  that  recom- 
mended for  corresponding  gastric  disease. 


*  Dr.  Hodgkin  on  '  The  Pathology  of  Serous  and  Macous  Membranes.' 
8 


114  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

Cask  LXXXVI. —  Ulceration  of  the  Duodenum.  Perforation. — 
George  E ,  aet.  30,  a  man  of  light  complexion,  and  of  steady  and  tem- 
perate habits,  was  admitted  into  Guy's  Hospital,  October,  1851.  He 
■was  by  trade  a  surgical  instrument  maker,  and  accustomed,  when  at 
work,  to  exercise  pressure  against  the  umbilicus.  Four  months  before 
admission  he  had  slight  expectoration  of  blood,  but  it  was  doubtful 
whether  it  proceeded  from  the  lungs  or  stomach.  On  October  20th,  whilst 
apparently  in  good  health,  he  suddenly  experienced  severe  pain  in  the 
abdomen;  to  use  his  expression,  he  was  "  doubled  up  ;  "  he  fell  down  in  a 
fainting  state,  and  was  taken  into  a  druggist's  shop,  where  ammonia  and 
some  castor  oil  were  administered.  The  pain  was  situated  on  the  right 
side.  On  admission,  he  was  in  a  state  of  collapse;  the  pain  of  which  he 
complained  passed  in  the  course  of  the  ureter.  On  the  following  morn- 
ing he  was  exceedingly  depressed,  the  skin  hot,  the  abdomen  tender,  and 
there  were  the  symptoms  of  general  peritonitis;  vomiting  of  coffee-ground 
fluid  came  on,  and  pulsation  was  felt  at  the  scrobiculus  cordis,  which  sug- 
gested the  idea  of  aneurism.  He  survived  fifty-six  hours.  On  exami- 
nation, the  peritoneum  was  found  to  be  intensely  inflamed;  lymph  was 
effused,  and  castor  oil  was  found  floating  in  the  peritoneal  cavity.  At 
the  first  part  of  the  duodenum,  about  one  inch  from  the  pylorus,  an  ulcer 
was  found  of  the  size  of  a  shilling;  and  at  its  base  there  was  a  circular 
opening,  the  third  of  an  inch  in  diameter.  In  the  stomach  several  small 
aphthous  ulcers  were  observed,  and  two  small  ones  were  covered  with 
coagula.  The  remaining  parts  of  the  small  intestine  were  healthy;  so 
also  the  caecum,  colon,  kidneys,  spleen,  and  liver. 

In  the  chest  there  were  old  pleuritic  adhesions  on  both  sides,  espe- 
cially on  the  left,  where  there  was  also  a  small  vomica,  with  indurated 
lung,  and  thickened  tubes. 

The  patient  was  only  thirty  years  of  age;  and,  as  he  believed,  in  good 
health,  though  evidently  of  feeble  constitutional  power,  as  indicated  by 
the  condition  of  the  lungs  and  the  previous  haemoptysis;  he  was  doubtless 
phthisical,  but  the  disease  of  the  duodenum  resembled,  in  its  insidious 
character,  corresponding  disease  of  the  stomach,  and  gave  no  previous 
indication  of  its  existence. 

The  treatment  of  the  patient,  before  his  admission,  precluded  all 
chance  of  recovery;  but  such,  unfortunately,  is  too  frequently  the  case. 
Brandy  and  castor  oil,  probably  both,  found  their  way  into  the  peritoneal 
sac;  and  the  necessary  removal  of  the  man,  at  first  into  a  druggist's  shop, 
then  to  his  own  home,  and  afterwards  a  considerable  distance  to  the  hos- 
pital, tended  to  induce  increased  extravasation  and  peritonitis;  the  judi- 
cious administration  of  opium  prolonged  life  many  hours. 

As  to  the  cause,  the  stooping  posture  at  his  work  probably  assisted 
to  produce  the  disease;  but  this  is  involved  in  much  obscurity. 

The  position  of  the  pain  did  not  point  out  the  seat  of  the  perforation; 
but  this  is  only  what  has  frequently  been  observed  in  cases  of  gastric 
ulcer;  the  pain  was  principally  in  the  right  iliac  fossa,  and  it  was  believed 
that  the  ileum,  or  appendix  caeci,  had  given  way. 

Mr.  Travers,  in  the  *  Medico-Chirurgical  Transactions,'  mentions  a 
case  of  perforation  of  the  duodenum,  about  a  finger's-breadth  from  the 
pylorus,  in  a  gentleman,  aged  thirty-five,  who  was  strumous,  but  consid- 
ered to  be  in  good  general  health.  There  was  a  large  irregular  ulcer  in 
the  first  part  of  the  duodenum,  with  a  small  perforation,  which  had  led  to 
fatal  peritonitis  and  death  in  thirteen  hours;  the  perforation  took  place 


DUODENUM.  115 

a  short  time  after  a  meal,  the  period  at  which  such  accidents  are  gener- 
ally found  to  occur. 

Case  LXXXVII. —  Chronic  Ulcer  in  the  Duodenum.  Carcinoma  of 
the  Liver.  Jaundice.  Granular  Kidneys.  Obliteration  of  the  Bile- 
Duct. — George  C ,  aet.  46,  was  admitted  into  Guy's  Hospital  December 

14,  1853,  and  died  January  4th.  For  a  fortnight  he  had  had  jaundice, 
vomiting,  and  typhoid  symptoms,  and  for  three  months,  after  exposure  to 
cold,  oedema  of  the  lower  extremities  had  been  present.  In  the  liver 
there  were  from  six  to  ten  carcinomatous  tubercles;  the  bile-duct  was  ob- 
literated near  its  opening  into  the  duodenum,  and  throughout  the  liver 
the  ducts  were  very  much  distended;  the  cells  of  the  liver  were  normal. 
In  the  first  portion  of  the  duodenum  there  was  a  chronic  ulcer,  about  an 
inch  in  diameter,  with  raised  thickened  edges,  but  not  cancerous  in  its 
character;  the  rest  of  the  intestine  was  healthy;  the  kidneys  were  large, 
and  their  surface  irregular  and  granular. 

The  disease  in  the  duodenum  was  not  discovered  till  after  death;  the 
cancerous  condition  of  the  liver,  inducing  pressure  on,  and  obliteration  of 
the  ducts,  and  the  albuminuria  appeared  sufficient  to  explain  all  the  symp- 
toms. The  ulcer  in  the  duodenum,  however,  was  in  a  chronic  and  passive 
condition,  but  nothing  was  ascertained  as  to  its  cause;  we  suppose  that 
intemperance  increased  it.  We  rarely  find  such  a  complication  of  disease 
as  cancer  of  the  liver,  acute  disease  of  the  kidney,  and  the  condition  of 
the  duodenum  just  mentioned. 

Case  LXXXVIII, — Strumous  Disease  of  the  Abdomen.     Perforating 

Ulcer  of  the  Duodenum  and  Ccecum. — Jane  B ,  aet.  18,  was  admitted 

into  Guy's  Hospital  February  19,  1860,  and  died  October  4th.  At  first 
the  most  prominent  symptom  was  vomiting,  which  was  supposed  to  be 
hysterical;  but  after  a  time  the  abdomen  began  to  swell,  diarrhoea  came 
on,  and  emaciation,  &c.,  increased,  and  these  signs  indicated  the  presence 
of  organic  disease.  On  inspection,  the  body  was  much  emaciated;  the 
legs  were  cedematous.  The  pleura  was  opaque,  from  the  recent  eifusion 
of  lymph,  and  the  lungs  were  studded  with  tubercle.  The  peritoneum 
was  acutely  inflamed;  the  intestines  were  reddened,  and  there  was  lymph 
upon  them;  there  were  tubercular  masses  upon  the  peritoneum,  covering 
the  liver.  On  withdrawing  the  caecum  a  small  collection  of  offensive  pus 
was  found  at  its  posterior  part,  and  the  abscess  communicated  with  the 
caecum  by  means  of  an  opening  about  an  inch  above  the  ileo-colic  valve. 
At  the  seat  of  perforation  was  a  transverse  ulcer,  the  edges  of  which  were 
injected;  the  ulcer  was  one  inch  in  length,  and  the  opening  one-third  of 
an  inch.  A  few  other  ulcers  were  observed  in  the  colon,  but  none  were 
found  at  the  termination  of  the  ileum.  The  mesenteric  glands  were  enor- 
mously infiltrated  with  cheesy  deposit;  so  also  were  the  lumbar  glands. 
Behind  the  first  portion  of  the  duodenum,  and  close  to  the  pancreas,  was 
a  collection  of  offensive  pus  in  front  of  the  spine.  This  abscess  commu- 
nicated with  the  first  portion  of  the  duodenum  by  an  opening  about  a 
quarter  of  an  inch  in  diameter;  the  ulceration  of  the  mucous  membrane 
was  more  extensive  than  the  external  opening;  and  near  to  the  perforation 
was  a  second  smaller  ulcer  involving  the  mucous  membrane.  The  first 
portion  of  the  duodenum  appeared  to  be  contracted.  The  stomach  was 
healthy,  so  also  the  kidneys.  The  spleen  contained  a  softening  strumous 
mass.     The  liver  also  was  fatty. 


116  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

Although  the  history  of  this  case  is  imperfect,  I  have  introduced  it  as 
an  illustration  not  only  of  the  obscurity  of  strumous  disease  in  its  earlier 
stage,  but  as  an  instance  of  irritation  of  the  duodenum  and  colon,  followed 
by  ulceration  and  perforation,  and  producing  peritonitis,  at  first  of  a  local, 
but  afterwards  of  a  general  character.  The  perforations  in  both  situa- 
tions were  not  directly  into  the  serous  cavity;  the  abscess  connected  with 
the  duodenum  was  close  to  the  pancreas  upon  the  spine,  and  the  one  in 
the  colon  was  placed  behind  the  caecum. 

In  an  interesting  case  of  haematemesis  under  my  care  in  Guy's  Hos- 
pital in  1875,  the  haemorrhage  which  proved  fatal  was  supposed  to  have 
come  from  the  stomach,  but  on  examination  after  death,  it  was  found  that 
a  large  ulcer  in  the  duodenum  had  perforated  the  intestine,  and  led  into  a 
sloughing  abscess  in  the  portal  fissure,  with  which  the  vena  portae  com- 
municated by  an  ulcerated  opening  partially  filled  by  clot;  the  common 
bile-duct  and  hepatic  duct  were  also  divided;  the  hepatic  artery  was  ob- 
literated.' 

It  is  probable  that  this  perforation  of  the  duodenum  was  from  without, 
as  was  also  the  case  in  a  patient  under  my  care  in  1866.  A  woman,  aged 
46,  died  a  few  weeks  after  admission,  and  a  large  abscess  was  found  on 
the  right  side  of  the  abdomen  in  the  neighborhood  of  the  ascending  colon, 
along  which  it  extended  to  the  duodenum,  where  it  opened  by  a  rounded 
aperture  an  inch  beyond  the  pylorus.  The  stomach  contained  a  little 
altered  blood.  The  patient  had  also  cancerous  disease  of  the  gall-bladder, 
which,  however,  had  no  apparent  connection  with  the  peritoneal  abscess. 

Case  LXXXIX. —  Gall-stone.  XTlceration  of  Gall-bladder  and  Duo- 
denum.  Large  Gall-stone  impacted  in  the  Jejunum.    Death  from  Hmmor- 

rhage. — A.  B. ,  aet.  56,  had  suffered  from  loss  of  appetite  and  mental 

depression  for  some  time,  due  to  family  anxiety  and  trouble.  He  was  a 
strong,  muscular  man,  rather  stout,  and  he  had  generally  enjoyed  good 
health.  On  November  29th,  after  a  late  dinner,  severe  pain  came  on  in 
the  region  of  the  stomach,  and  for  several  hours  was  very  intense;  there 
was  vomiting,  and  the  pain  extended  to  the  back.  On  the  following  day 
the  intense  pain  had  subsided,  but  left  soreness  at  the  stomach,  at  the 
scrobiculus  cordis  and  in  the  region  of  the  gall-bladder.  He  had  no  ap- 
petite, and  the  tongue  was  furred;  a  purgative  was  given  and  saline  med- 
icine. On  December  2d  he  had  become  jaundiced;  the  pulse  was  good, 
but  the  tongue  was  furred;  there  was  no  appetite  for  food,  but  much 
mental  depression.  The  symptoms  of  jaundice  gradually  lessened.  On 
December  15th  the  urine  was  still  deep  in  color,  but  the  motions  were 
less  pale.  He  lost  the  pain  at  the  stomach,  regained  his  appetite,  the 
urine  became  normal  in  color,  and  he  was  able  about  Christmas  to  visit 
his  friends;  the  skin,  however,  did  not  completely  regain  its  color.  On 
January  12th  he  returned  to  town,  feeling  tolerably  well,  but  during  the 
night  nausea  came  on.  On  Saturday,  13th,  sickness  supervened,  and  he 
took  blue  pill  with  colocynth;  the  bowels  acted  a  little.  On  the  14th  the 
vomiting  persisted,  and  saline  effervescing  medicines  were  prescribed;  in 
the  evening  vomiting  of  blood  occurred  mixed  with  acid  fluid.  On  Monday, 
January  15th,  I  saw  him  in  consultation.  The  stomach  was  very  irritable ; 
everything  was  at  once  rejected;  the  pulse  was  quiet,  80;  temperature 
normal;  the  abdomen  was  full,  but  there  was  no  tenderness;  he  complain- 
ed of  soreness  across  the  abdomen,  just  above  the  umbilical  region,  and 

>  See  'Path.  Trans.,'  vol  xxviL,  1876. 


DUODENUM.  117 

hardness  could  be  felt  at  the  scrobiculus  cordis,  which  was  thought  to  be 
the  left  lobe  of  the  liver;  there  was  no  fixed  pain,  and  no  evidence  of 
hernia.  Bismuth  medicine  in  effervescence  was  given,  and  a  dose  of 
calomel  with  colocynth.  On  the  16th  he  was  rather  easier,  but  there  was 
no  action  from  the  bowels;  the  pain  increased  in  the  afternoon;  the  cal- 
omel and  colocynth  were  repeated,  and  an  injection  used.  On  January 
17th  there  was  still  no  action  of  the  bowels;  a  dose  of  castor  oil  was  fol- 
lowed by  violent  vomiting  of  brown  acid  fluid;  no  flatus  was  passed;  the 
pulse  was  80,  temp.  98°,  the  respiration  easy;  the  abdomen  was  full  and 
supple,  and  tympanitic,  there  was  soreness  in  the  epigastric  region;  no 
peristalsis  could  be  seen.  It  seemed  evident  that  there  was  obstruction 
in  the  bowels;  purgatives  were  not  repeated,  but  a  grain  of  opium  was 
given,  and  a  turpentine  enema  was  used.  On  January  18th. — The  opium 
given  night  and  morning  had  relieved  the  sickness;  a  full  injection  of  oil 
and  afterwards  soap-and-water  produced  a  discharge  of  hard  scybala. 
Still  there  was  no  free  action  from  the  bowels;  the  pulse  was  80,  temper- 
ature still  normal,  the  abdomen  as  before;  the  urine  was  normal  in  color, 
tolerably  free  in  quantity,  sp.  gr.  1017,  and  it  contained  a  trace  of  albu- 
men. On  the  19th  he  felt  better  in  the  morning,  but  as  he  could  not 
pass  urine  freely  a  hip-bath  was  allowed.  About  4  p.m.  faintness  came 
on,  and  he  again  vomited  blood.  The  patient  became  restless.  Still 
there  was  no  action  from  the  bowels;  no  flatus  was  passed,  but  the  uri- 
nary bladder  being  distended  a  catheter  was  introduced,  and  about  a  pint 
of  urine  drawn  off.  Ice  was  applied  externally,  and  some  was  swallowed, 
and  astringents  given.  Nutrient  injections  were  used  repeatedly.  At  10 
p.m.  he  had  rallied;  about  a  pint  of  blood  mixed  with  acid  fluid  had  been 
rejected.  On  January  20th,  fibout  5  a.m.,  more  blood  with  clots  were 
vomited,  but  he  again  rallied.  On  the  21st  he  had  return  of  vomiting 
several  times;  in  the  evening  he  got  out  of  bed,  again  vomited  blood, 
faintness  followed,  and  he  died  about  8  p.m. 

Post-mortem  examination  hy  Dr.  Goodhart  twenty  hours  after  death. 
— Abdominal  wall  thickly  coated  with  fat.  On  opening  the  abdomen,  the 
omentum  and  liver  were  found  adherent  to  the  abdominal  wall  in  front 
at  the  upper  part.  The  jejunum  was  much  distended  and  dark  in  color; 
on  tracing  the  small  bowel  from  the  caecum  upwards,  the  ileum  was  small 
and  paler  till  its  upper  part  was  reached.  Here  it  was  blocked  by  a  gall- 
stone of  black  color,  somewhat  irregular  in  shape,  with  a  facet  at  either 
end  of  its  long  diameter,  and  measuring  about  1^  x  1^  inches.  It  moved 
about  in  the  bowel  under  external  manipulation  with  considerably  free- 
dom, though  it  would  not  pass  far,  and  it  quite  filled  the  canal.  Below, 
the  bowel  was  empty  or  nearly  so,  and  above,  it  was  considerable  dilated, 
and  contained  clayey  and  brownish  pultaceous  faecal  matter.  The  mucous 
membrane  where  the  stone  lodged  was  superficially  ulcerated  in  some 
parts.  About  three  inches  higher  up  was  a  smaller  gall-stone  more  like 
a  fragment  than  a  distinct  calculus.  It  lay  loose  in  the  intestine  with 
some  fluid,  brownish  faecal  matter,  and  was  easily  crushed  between  the 
fingers.  Nothing  else  abnormal  was  found  till  the  duodenum  was  reached. 
On  raising  the  right  lobe  of  the  liver  the  first  part  of  the  duodenum  was 
seen  to  be  pulled  upwards  and  adherent  to  the  fissure  for  the  gall-bladder, 
and  to  hide  the  gall-bladder  from  view.  The  latter  was  further  concealed  by 
the  omentum,  also  adherent  to  the  liver.  To  the  right  of  these  structures 
was  a  little  treacly  blood,  about  a  drachm,  lying  close  to  the  duodenum 
underneath  the  liver,  but  free  in  the  peritoneum.  Its  position  there  must 
have  been  of  recent  occurrence,  as  it  was  not  shut  in  by  adhesions,  and 


118  DISEASES    OP   THE   INTESTINES   AND    PERITONEUM. 

yet  no  peritonitis  was  present.  Dissecting  out  the  gall-bladder  and  the 
vessels  of  the  portal  fissure,  it  was  found  that  the  fundus  of  the  gall-blad- 
der, the  cavity  of  which  was  much  contracted,  opened  by  a  large  hole 
into  a  shreddy  cavity  which  contained  blood  of  treacly  consistency;  this 
cavity  also  opened  by  a  large  and  irregular  aperture  into  the  duodenum, 
immediately  beyond  the  pylorus  at  its  anterior  part.  The  vessels  of  the 
portal  fissure  ran  to  the  left  and  in  front  of  the  cavity  external  to  the 
gall-bladder,  and  they  were  not  implicated,  with  the  exception  of  the  main 
branch  of  the  hepatic  duct  to  the  right  lobe  of  the  liver.  This  was  quite 
destroyed,  and  the  truncated  extremity  opened  into  the  abscess  imme- 
diately behind  its  junction  with  the  duct  from  the  other  side  to  form  the 
main  hepatic  duct;  the  cystic  duct  was  also  destroyed.  All  the  other 
vessels  were  normal.  The  cystic  artery  of  the  pancreatico-duodenal,  the 
splenic  and  gastric  arteries  were  all  quite  sound,  and  so  also  were  all  the 
branches  of  the  portal  vein  in  the  neighborhood.  The  source  of  the  has- 
morrhage  could,  therefore,  only  be  attributed  to  a  venous  oozing  from  the 
surface  of  the  ulcer  in  the  gall-bladder  and  the  duodenum,  and  the  slough- 
ing cavity  outside.  The  liver  substance  was  unaffected  by  the  ulcerative 
action,  which  was  quite  external  to  the  capsule  of  the  organ.  The  liver 
was  small,  but  quite  healthy,  except  a  slight  excess  of  fat.  The  kidneys 
were  rather  large  and  coarse;  the  right  contained  a  cyst;  the  spleen  was 
pale  but  healthy.  The  lungs  were  emphysematous.  The  muscular  fibre 
of  the  heart  was  fatty. 

From  the  observations  I  had  made  in  November  I  felt  convinced  that 
the  patient  had  gall-stone,  and  I  supposed  it  had  passed,  although  one 
was  not  detected.  In  the  last  attack  the  haemorrhage  was  different  from 
that  which  we  generally  observe  in  gastric  ulcer;  the  blood  was  poured 
out  more  gradually.  The  clinical  history  was  not  that  of  gastric  ulcer, 
neither  was  the  haemorrhage  such  as  we  have  in  engorgement  of  the  por- 
tal circulation.  From  its  gradual  character,  I  thought  it  probable  that  it 
arose  from  the  duodenum  and  was  venous  in  character.  It  was  evident, 
also,  that  there  was  mechanical  obstruction  of  the  intestine,  for  purga- 
tives were  instantly  rejected,  no  true  action  from  the  bowels  took  place, 
and  no  flatus  was  passed.  It  occurred  to  me  that  possibly  a  gall-stone, 
impacted  high  up  in  the  small  intestine,  was  the  cause  of  the  obstruc- 
tion, and  this  opinion  was  confirmed  by  the  post-mortem  examination,  and 
also  that  the  haemorrhage  arose  from  an  ulcer  in  the  duodenum. 

No  peristaltic  movement,  although  several  times  looked  for,  could  be 
detected,  and  yet  the  gall-stone  was  pushed  down  to  the  end  of  the 
jejunum.  It  is  true  that  the  abdomen  was  covered  by  a  thick  stratum  of 
fat,  which  would  render  the  observation  of  movement  more  difficult  ; 
again,  the  intestine  was  filled  with  blood,  and  it  is  possible  that  the 
peristaltic  movements  were  very  feeble  on  account  of  the  haemorrhage. 
Another  circumstance  of  great  interest  was  the  comparative  absence  of 
pain,  although  an  enormous  gall-stone,  more  than  an  inch  in  diameter, 
had  ulcerated  its  way  through  the  gall-bladder,  then  outside  the  bile-duct, 
into  the  duodenum;  there  was  soreness,  but  no  severe  pain  and  no  rigor. 
This  comparative  absence  of  pain  I  have  previously  noticed  in  a  case 
where  a  large  gall-stone  had  led  to  fatal  obstruction  by  impaction  imme- 
diately beyond  the  duodenum. 

The  following  is  a  table  of  the  cases  in  which  we  have  found  ulcera- 
tion of  the  duodenum. 


DUODENUM. 


119 


Bex. 

Age. 

Disease  or  injnry. 

Canse  of  death. 

Bemarks. 

F. 

13 

Bam. 

Tetanus. 

Thirteen  days  after  ; 
stomach. 

M. 

4 

Bum. 

HaBmorrhoge. 

Ecchymosed  ulcer  on 
the  tongue. 

M.. 

•• 

Scald. 

Exhaustion. 

Braune  glands  swol- 
len. 

F. 

80 

Primary  disease. 

Portal  pyaemia. 

M. 

ay 

Amyloid  viscera. 

Scrofulous  pyelitis. 

M. 

,  , 

Diseased  knee. 

Haemorrhage. 

M. 

55 

Hydrocephalus. 

Convulsions. 

Hypertrophy  and  dila- 
tation ;  stomach. 

F. 

55 

Renal  disease. 

Large  white  kidney. 

F. 

12 

Disease  of  hip. 

Haemorrhage  from  ulcer. 

M. 

80 

Primary  disease. 

Perforation,  peritonitis. 

M. 

46 

Cancer  of  liver,  &c. 

Exhaustion  from  cjuicer,  «&c. 

F. 

18 

Tabes  mesenterica. 



Abscess  behind  cse 
cum,  &c. 

M. 

56 

Gall-stone. 

Haemorrhage  ;    gall-stone 
impacted. 

Ulcer  due  to  the  pas- 
sage of  a  gall-stone. 

Cancerous  disease  of  the  duodenum. — It  is  far  more  frequent  to  find 
the  duodenum  secondarily  involved,  than  to  be  itself  the  primary  seat  of 
this  fatal  form  of  disease.  In  many  cases  the  disease  appears  to  have 
commenced  in  the  pancreas  or  in  the  adjoining  lymphatic  glands,  or  in 
the  liver;  and  although  cancer  of  the  stomach  and  of  the  pylorus  is  gener- 
ally very  defined  and  ceases  abruptly  at  the  commencement  of  the  duo- 
denum, such  is  not  constantly  the  case,  for  the  disease  sometimes  extends 
onward  into  the  pyloric  portion  of  the  duodenum.  Again,  it  is  oftentimes 
very  difficult  to  state  precisely  in  which  part  the  disease  has  commenced. 

As  to  the  symptoms,  the  earlier  ones  are  often  very  insidious;  and 
are  more  likely  to  be  mistaken  for  hepatic  disease  than  the  early  symp- 
toms of  cancer  of  the  stomach;  still  the  first  indications  are  those  of 
dyspepsia  and  malaise,  sallowness  of  complexion,  mental  depression,  fol- 
lowed by  nausea,  vomiting,  and  sometimes  pain,  several  hours  after  food 
has  been  taken.  The  patient  emaciates,  and  a  hardness  or  tumor  is  felt 
about  the  cartilage  of  the  tenth  rib;  a  very  difficult  question  then  arises, 
as  to  whether  it  is  the  pylorus  that  is  affected,  or  the  pancreas,  or  the 
lymphatic  glands.  Pulsation  communicated  to  the  growth  may  suggest 
the  idea  of  aneurism.  In  aneurismal  disease  the  vomiting  is  a  less  marked 
symptom,  and  the  pulsation  more  uniform;  the  pain  also  is  often  very  in- 
tense. In  primary  pancreatic  disease  the  tumor  is  generally  more  central; 
the  evacuations  have  been  found  sometimes  to  contain  fat,'  and  until 
pressure  take  place  on  the  duodenum,  or  the  disease  extend  to  the  stomach, 
and  to  the  lymphatic  glands,  the  symptoms  are  less  pronounced.  Pyloric 
disease  is  indicated  by  more  persistent  vomiting  than  we  find  in  simple 
duodenal  disease.  Occasionally  local  ulceration,  with  chronic  thickening, 
takes  place  at  the  union  of  the  transverse  and  ascending  colon,  or  cancer- 
ous disease  may  be  developed  at  this  site,  and  subsequently  perforate  the 
duodenum.  (See  "  Cancer  of  the  Colon.")  The  formation  of  adhesions 
with  the  duodenum  in  these  latter  instances  sometimes  causes  partial 
mechanical  obstruction;  vomiting  is  produced,  and  thus  the  diagnosis  is 

'  The  observations  of  Bernard  tend  to  show  that  this  symptom  would  be  a  constant 
one,  if  the  duct  were  always  obstructed. 


120  DISEASES    OF   THE   IlfTESTINES   AND   PERITONEUM. 

rendered  unusually  difficult;  such  was  the  case  in  an  instance  wliict  we 
shall  presently  give.  In  all  these  maladies  there  is  emaciation,  pallor, 
cachexia.  Lastly,  we  must  refer  to  numerous  diseases  of  the  omentum 
and  of  the  liver  as  complicating  the  diagnosis.  Here,  however,  the  dilli- 
culty  is  less;  for  in  the  former  the  tumor  is  more  central,  there  is  greater 
mobility,  and  the  gastric  symptoms  are  less  marked;  in  the  latter,  hepatic 
cancer,  the  tumor  is  more  strictly  in  the  hypochondriura,  and  the  enlarged 
gland  may  be  often  felt  with  tubera  projecting  from  its  surface. 

The  termination  of  cancer  of  the  duodenum  is  generally  one  of  pro- 
gressive emaciation  and  cachexia.  If  enlarged  glands  press  upon  the 
bile-ducts,  jaundice  will  be  added  to  the  symptoms;  if  perforation  or 
sloughing  takes  place,  local  abscess  occasionally  forms,  which,  by  giving 
resonance  on  percussion,  adds  increased  difficulty  in  forming  a  correct 
diagnosis. 

The  treatment  of  these  cases  generally  consists  in  trying  to  relieve  the 
distress  and  pain  of  the  patient,  and  in  sustaining  his  exhausted  powers. 
Anodynes  are  required — opiun»,  morphia,  chloroform,  or  its  preparations; 
and  bland,  but  very  nutrient  diet,  and  especially  of  a  fluid  kind,  should 
be  given.  Stimulants  assist  in  keeping  alive  the  flickering  flame  of  life. 
When  great  sallowness  of  the  complexion  comes  on,  or  jaundice,  it  is 
very  unwise  to  give  mercurials;  they  hasten  degenerative  changes,  ex« 
haust  the  patient,  without  any  mitigation  of  his  sufferings,  and  tend  to 
hasten  the  fatal  termination. 

Case  XC. —  Cancer  of  the  Duodenum.  (Reported  by  Mr.  C.  Long- 
more.) — .lames  R ,  set.  40,  was  admitted  under  my  care  into  Guy's  Hos- 
pital, June  23,  1858,  and  died  July  5th.  He  was  by  trade  a  coach- 
builder,  and  he  had  resided  at  Newington;  his  habits  of  life  had  been 
temperate,  and  with  the  exception  of  a  slight  winter  cough,  he  had  en- 
joyed good  health  till  Christmas  of  the  preceding  year.  The  first  symp- 
tom of  which  he  complained  was  a  shooting  pain  in  the  back  and  stomach; 
the  pain  at  last  became  very  violent,  especially  at  night  after  he  had 
finisiied  his  work;  there  were  also  moving  pains  in  both  sides,  especially 
on  tlie  right,  and  in  the  testicles;  he  had  neither  cough  nor  vomiting; 
about  four  weeks  prior  to  his  admission  swelling  of  the  feet  came  on,  and. 
after  a  few  days  his  abdomen  began  to  swell.  He  was  a  man  of  sallow 
complexion,  with  dark  hair  and  eyes;  he  was  much  emaciated,  but  the 
feet  and  legs  were  anasarcous;  there  was  dulness  on  percussion  at  tlie 
sides  of  the  abdomen,  and  fluctuation  was  indistinctly  felt.  In  the 
scrotum  on  the  right  side  was  a  large  hernial  protrusion;  and  in  the  ab- 
dominal cavity  a  hard  tumor  could  be  felt,  situated  on  the  level  of  the 
umbilicus,  and  two  inches  to  its  left  side;  the  tumor  was  an  inch  and  a 
half  to  two  inches  in  diameter,  dull  on  percussion,  but  there  was  reso- 
nance around  it;  on  pressure  very  slight  pain  was  produced.  Over  the 
cartilage  of  the  tenth  rib  there  was  also  a  minute  pea-like  tumor.  The 
thoracic  viscera  were  apparently  healthy;  the  pulse  feeble,  compressible, 
70.  The  surface  of  the  body  was  cool.  The  tongue  was  coated  with  a 
brown  fur  in  the  centre,  but  was  red  at  the  tip.  The  bowels  were  freely 
acted  upon,  and  the  evacuations  were  paler  than  natural.  The  urine  was 
scanty,  sp.  gr.  1032,  free  from  albumen,  but  loaded  with  lithates.  Small 
doses  of  acetate  of  morphia  were  given,  and  dilute  nitric  acid  with  infu- 
sion of  cusparia.  On  June  25th  the  abdomen  had  greatly  increased  in  size, 
it  was  very  tense  and  resonant  on  percussion,  except  in  the  lumbar  regions. 
On  the  2Gth,  the  report  states  that,  during  the  previous  evening  and  on 


DUODENUM.  121 

this  day,  he  vomited  about  two  quarts  of  bitter  bilious  fluid,  but  became 
more  comfortable  after  its  rejection;  although  a  sensation  of  intense 
thirst  came  on.  On  the  28th  he  had  become  jaundiced,  and  complained 
of  great  pain  across  the  loins,  of  an  aching,  dragging  character. 

On  the  evening  of  the  3d  July  vomiting  of  coffee-ground  substance 
came  on,  and  continued  till  his  death  on  the  5th,  at  11  p.m.  The  tumor 
several  days  previously  seemed  larger  and  more  distinct.  Inspection 
was  made  sixteen  hours  after  death.  There  was  rigor  mortis;  the  whole 
body  was  jaundiced;  the  tissue  of  the  heart  was  pale  and  softened.  The 
liver  was  much  enlarged.  A  tumor  about  the  size  of  the  fist  surrounded 
the  vessels  at  the  fissure  of  the  liver;  the  duodenum  was  situated  in  front 
of  this  growth,  and  was  adherent  to  it.  The  commencement  of  the  duo- 
denum was  quite  destroyed  by  cancerous  ulceration,  and  a  large  slough 
occupied  the  position  of  the  first  portion.  The  interior  of  the  intestine 
communicated  with  the  cancerous  mass  beneath  it;  the  cancer  tumor  was 
altered  in  structure,  and  contained  blood.  The  gall-bladder  was  dis- 
tended to  about  twice  its  natural  size,  and  contained  a  few  gall-stones. 
The  hepatic  duct  was  slightly  obstructed.  The  vena  cava  was  in  several 
places  penetrated  by  the  cancerous  growth.  The  whole  liver  was  filled 
with  cancerous  tubera,  which  were  rounded,  vascular,  and  softened.  The 
disease  appeared  to  run  more  especially  in  the  course  of  the  portal  vessels, 
as  if  its  entry  into  the  liver  had  been  by  Glisson's  capsule.  The  cancer 
growth  consisted  of  large  nucleated  cells.  The  pancreas,  supra-renal 
capsules,  and  kidneys,  were  healthy. 

Instances  of  this  kind  are  often  very  difficult  of  diagnosis,  as  to  the 
precise  seat  of  the  disease;  the  glands  close  to  the  duodenum  were  prob- 
ably first  affected;  but,  although  really  behind  the  duodenum,  the  intes- 
tine did  not  cause  resonance,  probably  on  account  of  its  becoming  early 
implicated  in  the  disease.  The  subsequent  symptoms  arose  from  pressure 
on  the  bile-ducts  and  the  vena  porta?,  and  from  the  degeneration  of  the 
cancerous  growth.  Mr,  John  Dix,  of  Hull,  has  recorded  a  very  interest- 
ing case  somewhat  allied  to  this;  and  in  which  there  was  a  tumor  appar- 
ently connected  with  the  liver,  but  resonant  on  percussion.  "The  tumor 
was  hepatic  and  malignant.  It  was  softening  down — sloughing,  in  fact; 
and  in  this  process  it  had  involved  and  laid  open  the  duodenum,  to  which 
it  was  attached;  and  whence  air  had  escaped  into  a  circumscribed  cavity 
formed  by  the  tumor  behind,  and  the  abdominal  wall  in  front,  to  both  of 
which  the  transverse  colon  was  adherent  below,  forming  the  lower  bound- 
ary "  of  the  resonant  space.  The  patient,  "  Mrs.  M ,  aged  fifty-five,  was 

pallid,  feeble,  and  emaciated;  she  complained  chiefly  of  pain  in  the  right 
side  of  the  abdomen,  with  vomiting  and  other  symptoms  referable  to  de- 
rangement of  the  hepatic  and  digestive  functions.  She  had  suffered,  be- 
fore that  time,  from  jaundice  and  gall-stones."  She  died  in  about  three 
months  after  the  first  medical  examination;  but  the  resonance  in  front  of 
the  tumor  remained  till  death. 

Primary  cancer  of  the  duodenum  is  of  rare  occurrence;  a  patient,  under 
my  care  in  Guy's  in  1873,  aged  forty-five,  suffered  eighteen  months  before 
admission  from  violent  vomiting  and  purging;  for  a  week  he  was  jaun- 
diced, and  he  gradually  sank;  the  stomach  and  pylorus  were  healthy,  but 
the  first  portion  of  the  duodenum  was  occupied  by  a  large  cancerous 
growth  as  large  as  a  cricket-ball,  soft,  milky,  vascular,  and  invading  tha 
liver  by  direct  extension. 

Instances  also  occur  of  primary  disease  of  the  pancreas  extending  to 


122         DISEASES   OF  THE  INTESTINES    AND   PERITONEUM. 

the  duodenum,  and  we  have  witnessed  such  cases  in  which  the  mucous 
membrane  of  the  duodenum  had  become  infiltrated  with  medullary  cancer. 
Cancerous  cachexia  is  then  generally  well  marked,  but  till  the  pylorus  or 
duodenum  become  involved,  vomiting  is  not  generally  a  prominent  symp- 
tom. We  have  also  seen  the  duodenum  perforated  in  cancerous  disease 
of  the  caecum,  which  had  extended  upwards;  and  in  another  case,  one  of 
villous  cancer  of  the  bile-ducts,  a  large  cyst  had  formed  in  the  right  side 
of  the  abdomen  below  the  liver,  and  opened  into  the  upper  third  of  the 
duodenum  by  four  separate  ulcers. 

Mechanical  obstruction. — Other  parts  of  the  intestine  are  much  more 
liable  to  obstruction  of  a  mechanical  character  than  the  duodenum.  In 
the  course  of  several  years  we  have  observed,  or  have  found  recorded,  iso- 
lated cases  of  this  kind  of  obstruction,  arising  from  the  following  causes: — 

1.  Peritoneal  adhesions. 

2.  Gall-stones  of  large  size,  which  having  ulcerated  through  the  coats 
of  the  gall-bladder,  have  become  impacted  in  the  duodenum,  and  have  led 
to  fatal  obstruction. 

3.  Enlarged  glands,  infiltrated  by  cancer,  compressing  the  second  or 
third  part  of  the  duodenum. 

4.  Diseased  pancreas. 

5.  Hydatid  disease  of  the  liver,  opening  into  the  duodenum. 

6.  Foreign  bodies. 

It  is  exceedingly  common  to  find,  after  death,  that  adhesions  have 
taken  place  between  l\iQ  first  portion  of  the  duodenum  and  adjoining  vis- 
cera, either  the  inferior  surface  of  the  liver  and  gall-bladder,  or  the  trans- 
verse colon;  and,  in  many  instances,  the  impediment  to  the  free  passage  of 
the  chyme  is  so  slight  that  no  symptoms  point  to  any  disturbed  function. 
In  the  following  case  adhesions  with  the  colon  were  followed,  however, 
by  great  distention  of  the  first  part  of  the  duodenum;  but  there  was  also 
some  ulceration  of  the  same  part  of  the  intestine;  there  was  chronic  ulcer 
of  the  colon,  and  chronic  as  well  as  acute  peritonitis,  with  strumous  and 
glandular  disease,  so  that  there  was  considerable  difficulty  in  unravelling 
the  symptoms,  which  resembled  those  of  organic  disease  of  the  stomach. 
Still  we  believe  that  the  pain  and  the  vomiting,  several  hours  after  food 
had  been  taken,  were  the  result  of  this  duodenal  obstruction. 

Case  XCI. —  Chronic  Peritonitis.  Acute  Peritonitis.  Tubercular 
Deposit  on  the  Serous  Membranes  and  in  the  Glands.  Constriction  of 
the  Duodenum,  and  great  Dilatation  of  its  first  portion.     Small  Ulcer  in 

the  Duodenum.     Larrje  Chronic  Ulcer  in  the  Colon. — William  C ,  ret. 

38,  was  admitted  into  Guy's  Hospital  under  my  care,  April  15,  1861. 
He  was  a  married  man,  by  trade  a  cooper,  and  he  had  resided  at  Dock- 
head.  About  seven  years  previously  he  suffered  from  severe  pain  at  the 
epigastric  region ;  and  for  several  years  since  that  time  he  had  had  pain 
at  the  same  part,  but  less  acute  in  its  character.  He  had  never  had  any 
haemorrhage  from  the  stomach,  but  he  had  complained  of  slight  pain  in 
the  dorsal  region,  between  the  sixth  and  eighth  vertebrae.  Some  years 
before  he  had  had  violent  vomiting;  but  since  that  time  vomiting  had  been 
slight,  the  attacks  coming  on  some  time  after  food  had  been  taken.  He 
had  had  slight  pyrosis,  and  acid  taste  after  vomiting.  The  pain  at  the 
epigastric  region  was  not  constant,  but  it  was  worse  after  food,  and  was 
especially  aggravated  by  constipation. 

On  admission  he  was  very  much  emaciated,  with  a  sallow  complexion, 
and  on  the  forehead  there  was  a  bronzed  condition  of  his  skin;  the  skin  at 


DUODENUM.  123 

the  elbows  was  also  slightly  discolored.  There  was  moderate  tenderness 
at  I  he  scrobiculus  cordis;  the  abdomen  was  rounded  and  supple;  no  tumor 
could  be  felt;  the  bowels  were  rather  confined;  the  pulse  was  very  com- 
pressible; the  tongue  was  red  in  patches.  No  disease  could  be  detected 
in  the  lungs  or  heart.  The  patient  stated  that  the  bronzed  color  of  the 
forehead  had  existed  for  three  years,  and  had  been  produced  by  exposure 
to  the  sun;  the  lower  part  of  the  abdomen  was  also  found  to  be  slightly 
discolored. 

On  April  20th  the  bowels  were  freely  moved,  and  he  had  severe  pain 
at  the  scrobiculus  cordis;  the  pain  was  neither  relieved  nor  modified  by 
any  change  of  position. 

He  continued  in  the  same  prostrate  condition,  without  pain  or  vomit- 
ing, till  June  11th,  when  violent  pain  and  symptoms  of  acute  peritonitis 
came  on,  and  he  sank  on  the  13th. 

14th. — Inspection. — The  body  was  very  much  emaciated.  Chest. — On 
the  left  side  the  pleura  was  firmly  adherent,  and  on  tearing  it  away, 
rounded,  yellowish  tubercles,  two  to  three  lines  in  diameter,  were  found 
thickly  covering  the  costal  surface.  The  left  lung  itself  was  very  small; 
but  there  were  no  tubercles  in  it.  The  right  pleura  was  free  from  adhe- 
sions or  tubercles,  and  the  lung  was  also  quite  healthy.  The  heart  and 
pericardium  were  normal.  There  were  several  yellowish-white  tubercular 
masses  in  the  glands  in  the  anterior  mediastinum.  On  opening  the  abdo- 
men, the  intestines  were  seen  to  be  distended;  and  the  enlarged  transverse 
colon,  extending  from  one  hypochondriac  region  to  the  other,  prevented 
the  stomach  from  being  seen.  There  were  numerous  peritoneal  adhesions, 
especially  at  the  upper  part  of  the  abdomen,  the  transverse  colon,  stom- 
ach, and  duodenum  being  united  firmly  to  the  under  surface  of  the  liver. 
The  coils  of  the  small  intestine  presented  considerable  injection  at  their 
lines  of  contact;  but  neither  was  lymph  effused,  nor  had  the  serous  mem- 
brane lost  its  shining  color.  Numerous  tubercles  were  present  on  the  se- 
rous membrane;  some  were  exceedingly  small,  others  three  or  four  lines  in 
diameter,  and  they  were  situated  on  the  intestines  or  on  the  peritoneal 
surface  of  the  liver.  The  mesenteric  glands  were  extensively  diseased; 
and  all  the  glands  situated  in  the  neighborhood  of  the  pancreas,  and  near 
the  origin  of  the  thoracic  duct,  were  enlarged,  although  it  could  not  be 
demonstrated  that  the  duct  was  compressed.  The  glands  contained  much 
cheesy  and  cretaceous  matter,  and  some  more  recent  semi-transparent  de- 
posit. On  removing  the  transverse  colon,  the  stomach  was  found  to  be 
distended,  and  an  elongated  sac  was  produced,  partially  contracted,  about 
three  inches  from  the  right  extremity;  this  sac  was  at  first  supposed  to  be 
from  hour-glass  contraction  of  the  stomach,  but,  on  opening  it,  the  first 
contraction  was  seen  to  be  pylorus,  and  the  second  enlargement  was  an 
enormously  distended  first  part  of  the  duodenum.  The  stomach  and  duo- 
denum contained  grayish-green  fluid  and  mucus.  The  mucous  membrane 
of  the  stomach  did  not  present  any  abrasion,  thickening,  nor  ulceration, 
nor  was  the  pylorus  hypertrophied;  there  was  a  little  arborescent  injec- 
tion. The  sac  formed  by  the  first  part  of  the  duodenum  was  capable  of 
holding  eight  to  ten  ounces  of  fluid,  and  was  also  injected.  Immediately 
beyond  the  pylorus  was  a  small  ulcer  about  five  lines  by  three  in  size,  its 
edges  rounded  and  without  any  injection;  it  did  not  extend  into  the  mus- 
cular coat.  Three  inches  from  the  pylorus  the  intestine  was  narrowed, 
and  there  was  a  constriction  resembling  a  second  pylorus;  there  was  no 
thickening  nor  cicatrix,  and  it  appeared  probable  that  the  peritoneal  ad- 
hesions had  looped  up  the  intestine.     On  the  gastric  side  of  this  constric- 


124         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

tion  there  was  a  small  pouch,  capable  of  admitting  the  tip  of  the  finger. 
The  rest  of  the  duodenum,  the  jejunum,  and  the  ileum,  were  healthy, 
with  the  exception  of  one  or  two  small  ulcers  with  tubercular  deposit  on 
their  peritoneal  surface.  Peyer's  glands  were  healthy.  The  crecum  and 
appendix  also  were  normal.  In  the  ascending  colon  the  solitary  glands 
were  very  distinct,  and  at  the  commencement  of  the  transverse  colon  were 
the  remains  of  an  old  ulcer;  for  two  to  three  inches  the  mucous  membrane 
was  irregularly  destroyed  and  puckered,  and  of  a  gray  color.  The  rest  of 
the  intestine  was  normaL  The  supra-renal  capsules,  the  kidneys,  and  the 
liver,  were  healthy;  two  or  three  strumous  tubercles  were,  however,  sit- 
uated on  the  peritoneal  surface  of  the  liver. 

In  mechanical  duodenal  obstruction  from  the  second  cauae,  impaction 
of  a  gall-stone,  the  symptoms  resemble  those  produced  by  internal  strangu- 
lation of  the  intestine,  or  by  hernia,  but  vomiting  is  set  up  at  a  very  early 
period,  and  is  of  a  severe  character.  The  vomited  matters,  however,  can- 
not have  a  stercoraceous  odor  nor  appearance.  The  diagnosis  is  generally 
obscure  and  difficult;  but  where  the  symptoms  of  the  passage  of  a  gall- 
stone, namely,  intense  pain  in  the  hypochondrium,  vomiting,  and  subse- 
quent jaundice,  are  followed  also  by  the  symptoms  of  insuperable 
obstruction,  the  nature  of  the  malady  is  sufficiently  clear;  but  in  the 
ulceration  of  a  large  gall-stone  through  the  coats  of  the  gall-bladder  into 
the  duodenum,  the  indications  of  disease  may  be  so  slight  as  to  be  almost 
overlooked,  and  the  subsequent  obstruction  cannot  then  be  distinguished 
from  strangulation  taking  place  high  up  in  the  intestine.  The  impaction 
of  the  gall-stone  is  generally  found  to  happen  near  the  termination  of  the 
duodenum,  or  in  the  upper  part  of  the  jejunum. 

In  obstruction  from  diseased  lymphatic  glands  in  the  neighborhood  of 
the  duodenum,  the  occlusion  sometimes  becomes  suddenly  complete,  and 
the  symptoms  are  those  of  internal  strangulation;  but  more  frequently 
the  pressure  is  less,  and  the  symptoms  are  those  which  we  shall  presently 
have  to  refer  to  in  connection  with  disease  of  the  pancreas;  thus,  in  an 
instance  of  femoral  hernia  after  the  intestine  had  been  returned,  the 
symptoms  continued,  and  the  patient  quickly  died.  The  third  portion 
of  the  duodenum  was  then  found  to  have  become  firmly  impacted  between 
two  enlarged  glands. 

Case  XCII. —  Obstruction  from  Biliary  Calcvlus  in  the  upper  part  of 
the  Jejunum,  thirty  inches  from  the  Pylorus. — The  calculus  is  in  the  mu- 
seum of  Guy's.  The  case  was  under  the  care  of  Ebenezer  Pye  Smith, 
Esq.,  and  is  recorded  in  the  '  Pathological  Transactions  '  of  1854.  The 
patient  was  a  stout  woman,  aet.  62.  She  had  good  health  till  three  months 
before  death,  when  she  suffered  slight  pain  in  the  right  hypochondrium, 
which  continued  a  fortnight,  unaccompanied  by  sickness  or  prostration. 
She  recovered,  but  continued  her  usual  sedentary  habits;  five  days  before 
her  death  she  began  to  feel  sick,  and  vomited  bile  in  large  quantities;  the 
urine  was  moderately  secreted.  The  vomiting  increased  in  violence,  but 
with  only  very  slight  pain  in  the  abdomen;  on  the  fifth  day  she  became 
comatose.  A  calculus  composed  of  inspissated  bile,  and  measuring  four 
and  a  half  inches  in  the  circumference  of  its  long  by  two  and  a  half  in  the 
circumference  of  its  short  axis,  was  found  impacted  about  thirty  inches 
from  the  pylorus.  There  was  much  fibrous  tissue  on  the  under  surface 
of  the  liver;  and  an  ulcerated  opening  extended  from  the  gall-bladder 
into  the  duodenum,  below  the  bile-ducts. 


DUODENUM.  125 

The  case  just  recorded  of  gall-stone  with  haemorrhage  ar.d  obstruc- 
tion is  of  a  somewhat  similar  kind.  An  interesting  case  id  recorded  by 
Dr.  T.  S.  Gray  in  the  *  Transactions  of  the  Clinical  Society  for  1873,'  in 
which  a  large  gall-stone  led  to  obstruction  and  stercoraceous  vomiting, 
but  was  subsequently  discharged,  and  the  patient,  a  man  aged  40,  re- 
covered. 

There  are  in  these  cases  three  symptoms  which  especially  deserve  at- 
tention, as  guiding  us  to  a  right  diagnosis,  when  viewed  in  connection 
with  the  previous  history.  The  absence  of  abdominal  distention,  the 
early  period  at  which  vomiting  takes  place,  with  the  character  of  the 
ejected  matters,  and  the  diminution  in  the  quantity  of  urine  which  is 
voided. 

The  absence  of  distention  of  the  abdomen  is  an  important  sign  of  oc- 
cluded intestine  in  the  early  part  of  its  course.  In  obstruction  of  the 
large  intestine,  or  even  at  the  lower  part  of  the  small,  the  abdomen  be- 
comes enormously  distended,  and  the  peristaltic  movements  can  often  be 
observed  in  spare  persons  through  the  parietes;  this  is  especially  the  case 
in  disease  of  the  sigmoid  flexure  of  the  colon.  The  stoutness  of  the  pa- 
tient sometimes  renders  this  sign  less  observable;  again,  where  this  duod- 
enal obstruction  exists  with  hernia,  the  diagnosis  must  necessarily  be 
most  obscure.  As  to  vomiting,  it  comes  on  very  early,  and  the  matters 
rejected  are  bilious.  In  strangulation  of  the  ileum,  and  obstruction  of 
the  colon,  unless  irritating  purgatives  are  given,  this  distressing  symptom 
may  be  considerably  postponed;  and  when  it  does  take  place  and  is  con- 
tinued, the  matters  are  of  a  stercoraceous  character.  Still,  in  acute  peri- 
tonitis, as  from  perforation,  the  sudden  bilious  vomiting  may  greatly 
mislead  us.  Again,  very  violent  bilious  vomiting  sometimes  takes  place 
in  disease  of  the  stomach,  and  in  cerebral  disease;  but  the  signs  of  ob- 
struction are  then  wanting. 

Gall-stone  produces  intense  pain  in  the  region  of  the  gall-bladder,  ac- 
companied with  vomiting  and  constipation;  this  severe  character  of  pain 
we  do  not  find  in  intestinal  obstruction,  but  it  must  be  acknowledged, 
that  when  slow  ulcerative  absorption  has  taken  place  between  the  walls  of 
the  gall-bladder  and  the  duodenum,  a  calculus  so  extruded  is  followed  by 
less  severe  suffering  than  in  ordinary  cases  of  biliary  calculus. 

A  very  interesting  case,  under  the  care  of  Dr.  Lever,  is  mentioned  by 
Dr.  Barlow  in  the  '  Guy's  Reports'  for  1844: — The  patient,  aged  fifty- 
one,  a  year  before  her  death  had  the  symptoms  of  gall-stone,  and  the  bow- 
els afterwards  became  constipated;  a  short  time  before  her  death  exces- 
sive pain,  vomiting,  and  constipation  came  on,  with  scanty  urine  and  col- 
lapsed abdomen.  The  gall-bladder  and  duodenum  were  firmly  adherent; 
the  two  upper  thirds  of  the  duodenum  were  contracted,  thickened,  and 
would  only  admit  a  common  quill;  about  the  centre  of  the  ileum  was  a 
biliary  calculus  of  the  size  of  a  walnut,  partially  sacculated. 

With  regard  to  the  quantity  of  urine  excreted  being  a  sign  of  the  seat 
of  obstruction,  as  mentioned  in  the  paper  by  Dr.  Barlow,  just  referred  to, 
he  argues  that  the  quantity  of  urine  must  necessarily  be  small,  from  the 
diminished  fluid  brought  within  the  range  of  the  absorbing  surface  of  the 
portal  veins;  and  thus  there  must  be  diminished  supply  to  the  heart  and 
kidneys;  but  there  is  often  a  large  quantity  of  fluid  ejected  by  vomiting 
which  would  proportionately  lessen  the  renal  secretion.  If  the  obstruction 
be  incomplete,  or  low  down  in  the  intestine,  the  kidneys  pour  out  a  larger 
quantity,  and  the  vomiting  is  also  less  severe. 

Dr.  Barlow  has,  in  the  paper  previously  cited,  dwelt  upon  the  impor* 


126  DISEASES    OF   TIIE   INTESTINES   AND    PERITONEUM. 

tance  of  bearing  in  mind,  that  in  ischuria  renalis,  violent  vomiting,  con- 
stipation, and  scanty  urine  are  sometimes  present. 

In  diseased  pancreas  the  obstruction  is  less  complete,  but  it  acts  by 
inducing  firm  adhesions  about  the  first  and  second  portions  of  the  duod- 
enum; and  pressure  is  also  exerted  by  the  increased  size  and  hardness  of 
the  pancreas,  and  by  infiltrated  glands.  The  symptoms  resemble  those 
of  obstructed  pylorus,  namely,  vomiting  several  hours  after  food,  grad- 
ually increasing  emaciation,  with  constipation;  and  these  symptoms  are 
slowly  developed  during  several  months.  A  tumor  can  generally  be  felt 
near  the  region  of  the  pylorus. 

The  following  very  interesting  case  was  regarded  as  one  of  cancerous 
disease  of  the  glands  in  the  neighborhood  of  the  pancreas,  and  secondary 
implication  of  the  stomach;  for  the  vomiting  took  place  three  or  four 
hours  after  a  meal,  as  in  obstructive  disease  of  the  pylorus;  and  the  gen- 
eral symptoms  resembled  those  of  organic  gastric  change. 

Cash  XCIII. — Disease  of  the  Pancreas.  Suppuration  and  Gangrene. 
Pressure  on  the  Duodenum,. — James  P ,  aet.  60,  by  occupation  a  pub- 
lican, and  resident  at  Camberwell,  was  admitted  under  my  care  on  July 
4,  1861.  He  stated  that  he  had  always  enjoyed  good  health  till  four 
months  prior  to  admission,  when  he  was  suddenly  seized  with  severe  pain 
in  the  region  of  the  stomach,  and  with  vomiting.  The  vomiting  returned 
at  intervals  of  three  or  four  days,  and  came  on  several  hours  after  food. 
Four  years  previously  he  had  begun  to  feel  slight  pain  at  the  region  of 
the  stomach,  which  came  on  every  three  or  four  months,  but  was  relieved 
by  taking  a  little  cayenne  pepper  with  brandy.  He  had  not  received  any 
blow,  nor  had  he  suffered  from  any  haematemesis.  The  pain  was  situated 
at  the  epigastric  and  umbilical  regions,  and  extended  to  the  spine;  it  was 
of  an  acute  kind,  and  had  not  the  gnawing  character  of  pain  often  de- 
scribed by  patients  affected  with  ulcer  of  the  stomach. 

On  admission  he  was  very  much  emaciated,  with  an  anxious  counte- 
nance, sallow  complexion,  and  sunken  eyes;  his  skin  was  hot  and  dry,  and 
he  complained  greatly  of  thirst;  the  tongue  was  furred,  the  pulse  frequent 
and  sharp,  the  respiration  normal;  he  had  slight  cough,  but  it  did  not  dis- 
tress him;  and  there  was  no  evidence  of  thoracic  disease  by  percussion 
nor  by  auscultation.  The  abdomen  was  contracted  moderately,  except  at 
the  lower  part  of  the  epigastric  and  at  the  umbilical  region,  where  there 
was  a  rounded  tumor,  evident  on  visual  examination.  The  tumor  was 
dull  and  tender  on  percussion;  no  fluctuation  could  be  felt,  and  it  had 
slight  pulsation  anteriorly  from  contact  with  the  aorta,  but  no  general 
aneurismal  thrill.  There  was  resonance  between  the  tumor  and  the  liver, 
as  well  as  between  the  tumor  and  the  spleen;  in  fact,  both  the  hypochon- 
driac regions  were  more  than  usually  resonant.  Pressure  on  the  tumor 
produced  a  feeling  of  nausea;  the  bowels  were  constipated;  and  the  ap- 
petite was  very  poor.  His  weakness  compelled  him  to  remain  quietly  in 
bed.  The  urine  was  high  colored  and  scanty,  and  was  free  from  albumen. 
Fluid  food  was  ordered,  and  soda-water  with  brandy,  and  chloric  ether, 
TTlx.,  with  nitrate  of  bismuth,  gr.  x.,  in  mucilage  mixture. 

July  5th. — He  was  slightly  relieved  by  the  medicine,  but  the  vomit- 
ing continued;  the  ejected  matters  consisted  of  deep-green  fluid,  con- 
taining a  large  quantity  of  mucus,  of  squamous  epithelium,  and  some 
nucleated  cells  (from  gastric  glands).  These  attacks  of  vomiting  dis- 
tressed him  greatly;  every  kind  of  food  was  rejected  at  once,  but  the 
medicine  and  ice  partially  relieved  his  distress;  his  prostration,  however, 


DUODENUM.  127 

increased;  hiccough  distressed  him;  and  he  had  an  offensive  taste  in  the 
mouth. 

July  8th. — He  was  extremely  restless  and  prostrate,  and  the  vomited 
matters  were  of  very  deep-green  color.  At  9  p.m.  he  was  suddenly  taken 
worse,  and  continued  in  great  pain  during  the  night.  At  7  a.m.  next 
morning  he  expired. 

Inspection  seven  hours  after  death. — The  body  was  very  much  emaci- 
ated. The  thoracic  viscera  were  healthy,  excepting  old  pleuritic  adhe- 
sions. The  peritoneum  contained  some  dirty  gray  fluid,  and  had  in  some 
parts  lost  its  shining  smoothness;  the  intestines  were  slightly  distended. 
The  sac  of  the  lesser  omentum  was  distended  by  a  large  abscess,  which 
had  constituted  the  tumor  felt  during  life.  On  tracing  the  duodenum 
upwards,  at  its  centre  was  found  an  oedematous  portion  bulging  out,  and 
containing  fluid  resembling  that  in  the  peritoneum;  but  there  was  no  per- 
foration. By  dividing  the  peritoneum  between  the  stomach  and  the 
colon,  an  abscess  was  opened;  it  had  dense  fibrous  walls,  about  two  lines 
in  thickness,  in  some  parts  irregularly  sinuous,  and  having  several  bands 
on  its  walls,  the  remains  of  occluded  vessels.  Above  and  partly  in  front 
of  the  abscess  was  the  stomach;  below  was  the  colon,  and  at  its  superior, 
right,  and  inferior  parts  was  the  duodenum  greatly  distended,  and  its 
coil  enlarged.  The  abscess  contained  dirty  offensive  pus,  and  at  its  pos- 
terior part  was  a  black  slough  about  two  and  a  half  inches  in  length; 
some  concrete  yellow  matter  was  also  found  on  its  walls.  The  abscess 
rested  on  the  spine,  the  crura  of  the  diaphragm,  and  on  the  superior  mesen- 
teric and  splenic  veins  as  they  formed  the  vena  portae.  It  extended  on 
the  left  to  the  spleen.  The  pancreas  for  two  to  three  inches  towards  the 
splenic  extremity  was  healthy,  but  the  rest  of  the  gland  was  in  a  sloughy 
state,  and  constituted  the  black  mass  found  at  the  floor  of  the  abscess. 
The  pancreatic  duct  existed  in  the  centre,  and  degenerating  gland  tissue 
was  observed  under  the  microscope.  The  gland  and  duct  were  separated 
from  their  duodenal  attachment.  The  common  bile-duct  was  healthy, 
and  its  opening  into  the  duodenum  was  free;  but  the  gall-bladder  con- 
tained numerous  gall-stones  about  the  size  of  peas.  The  liver  and  spleen 
were  healthy.  The  stomach  was  very  much  enlarged  and  distended;  it 
contained  tenacious  green  mucus,  such  as  was  vomited  during  life;  its 
mucous  membrane  presented  numerous  points  of  arborescent  injection,  so 
also  that  of  the  duodenum;  but  no  direct  communication  with  the  abscess 
could  be  found,  nor  any  ulceration  of  the  surface. 

The  origin  of  the  disease  in  this  remarkable  case  could  not  be  ascer- 
tained, viz,,  whether  a  pancreatic  calculus  had  set  up  the  abscess,  or 
whether  inflammation  had  been  produced  in  the  cellular  tissue  about  the 
gland.  No  direct  blow  had  been  received,  and  the  disease  slowly  ad- 
vanced. Acute  peritonitis,  from  the  transudation  of  offensive  purulent 
serum  into  the  general  cavity  of  the  peritoneum,  was  the  cause  of  the 
fatal  termination. 

Dr.  Bright  believed  that  the  fatty  motions  which  he  found  in  some  of 
these  cases  were  indicative  of  disease  of  the  pancreas;  but  this  symptom 
has  not  been  constantly  observed  in  pancreatic  disease,  possibly  from  the 
duct  being  only  partially  occluded. 

The  course  taken  by  hydatid  disease  of  the  liver  is  uncertain;  some- 
times it  is  towards  the  surface,  and  a  rounded  tumor  is  then  felt  on  the 
anterior  abdominal  parietes;  or  it  extends  through  the  diaphragm  into 
the  lungs.     In  a   case  under  the  care   of  Dr.   Rees,  in  Guy's,  the  cyst 


128  DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

opened  into  the  duodenum.  Hydatids  were  both  vomited  and  passed  by 
stool,  and  the  former  symptom  was  very  severe.  The  patient  was  ex- 
ceedingly ill,  and  a  friction  sound  was  audible  over  the  seat  of  the 
tumor,  evidently  from  local  peritonitis;  the  patient  steadily  improved 
after  the  evacuation  of  the  hydatids  by  vomiting;  the  tumor  disappeared, 
and  he  left  the  hospital;  but  after  a  few  weeks  intense  peritonitis  came 
on,  and  he  quickly  died.  The  remains  of  hydatids  were  found  in  the 
liver;  and  the  duodenum,  colon,  liver  and  kidney,  were  firmly  united  by 
adhesions.  A  large  abscess  existed  between  these  structures,  and  had 
led  to  the  fatal  peritonitis.  No  communication  existed  between  the  liver 
and  the  colon;  and  although  the  duodenum  at  its  second  part  was  firmly 
adherent,  no  direct  opening  could  be  found. 

The  patient  was  twenty-nine  years  of  age,  and  had  resided  at  Twick- 
enham; he  was  temperate  in  his  habits;  for  nine  years  he  had  suffered 
from  so-called  "  bilious  attacks,"  and  from  vomiting,  with  slight  sallowness 
of  the  skin;  five  years  previously  he  had  had  severe  jaundice,  which  con- 
tinued for  three  weeks.  Eight  months  before  admission  his  appetite  be- 
came ravenous,  but  he  lost  strength  and  became  emaciated;  for  seven 
weeks  he  had  been  confined  to  his  bed  from  severe  pain  about  the  umbili- 
cal region;  jaundice  came  on,  but  disappeared,  and  was  followed  by  very 
severe  pain  in  the  right  hypochondriac  region,  extending  to  the  loins,  and 
a  rounded  growth  presented  itself  below  the  ribs  on  the  right  side. 

A  remarkable  instance  of  mechanical  obstruction  in  the  duodenum, 
from  a  foreign  body,  is  recorded  by  Dr.  Blakeley  Brown,  in  the  '  Patho- 
logical Transactions'  of  1851  and  1852: — A  delicate  young  woman,  aged 
eighteen,  became  gradually  emaciated,  and  at  last  died  from  peritonitis. 
The  stomach,  duodenum,  and  upper  part  of  the  jejunum,  contained  casts 
composed  of  agglutinated  and  interwoven  masses  of  string  and  hair. 

Gastric  Solution  of  Duodenum. — The  mucus  of  the  duodenum  is  fre- 
quently found  in  an  acid  condition  after  death,  which  is  probably  due  to 
some  of  the  gastric  juice  slowly  gravitating  through  the  pylorus;  but  in 
some  instances  the  pylorus  is  so  patulous,  that  gastric  juice  readily  passes, 
and  exerts  its  solvent  power  after  death  in  the  same  manner  as  in  the 
stomach.  Such  a  state  was  found  in  a  child  who  died  under  my  care  in 
Guy's. 

Case  XCIV. — Perforation  of  Duodenum,  after  Death  from  Solution 

by  Gastric  Juice. — William  B-- ,  set.  4,  was  admitted  July  16,  1856, 

and  died  on  the  23d.  He  was  an  anremic  child,  with  large  head;  on  ad- 
mission he  was  in  a  semi-comatose  state,  and  the  pupils  were  widely  di- 
lated; he  had  occasional  vomiting,  but  no  convulsions;  six  weeks  previously 
he  had  had  measles,  and  one  week  afterwards  hydrocephalus  gradually 
became  developed;  he  was  in  an  almost  hopeless  condition  on  admission. 

Inspection  was  made  fourteen  hours  after  death.  The  arachnoid  was 
covered  with  a  slight  layer  of  lymph,  so  as  to  give  it  a  greasy  appear- 
ance, and  at  the  base  of  the  brain  there  was  considerable  sub-arachnoid 
effusion.  The  ventricles  contained  two  ounces  of  fluid,  of  sp.  gr.  1001. 
There  were  miliary  tubercles  in  the  lungs  and  in  the  bronchial  glands. 

In  the  stomach  there  was  considerable  gastric  solution,  the  mucous 
membrane  being  destroyed;  but  in  the  duodenum  the  intestine  was  quite 
divided,  all  the  coats  destroyed,  and  the  end  of  the  first  portion  termi- 
nated in  an  irregular  ragged  margin.  The  contents  of  the  stomach  were 
found  in  the  peritoneal  cavity.  There  were  tubercles  in  the  mesenteric 
glands,  and  an  isolated  one  in  the  kidney. 


DISEASES  OF  THE  RECTUM  AND  ANUS. 

By  Thomas  Blizard  Cueling,  F.R.S. 


An  acquaintance  with  the  numerous  disorders  of  the  lower  bowel  is 
absolutely  necessary  to  qualify  the  medical  practitioner  to  form  a  right 
diagnosis  and  judgment  of  the  diseases  of  adjacent  organs,  as  well  as  of 
the  alimentary  canal.  Thus,  complaints  of  the  rectum  are  liable  to  be 
mistaken  for  affections  of  the  uterus  and  even  of  the  bladder;  a  discharge 
from  a  fistula  in  ano  has  been  supposed  to  proceed  from  the  vagina.  Pa- 
tients have  been  treated  for  obstinate  diarrhoea,  when  the  actual  disease 
has  been  stricture  in  the  lower  bowel,  or  a  lacerated  peringeum  and  sphinc- 
ter; and  obstructions  referred  to  the  abdominal  intestines  have  been  dis- 
covered when  too  late  to  exist  in  their  pelvic  termination.  The  following 
is  a  table  of  the  diseases  of  the  rectum  and  anus;  they  can  be  treated  of 
only  very  concisely  in  the  space  allotted  to  this  subject: — Congenital  Im- 
perfections; Haemorrhoids;  Prolapsus  of  the  Rectum;  Irritable  Ulcer; 
Irritable  Sphincter;  Nervous  Affections  of  the  Rectum;  Villous  Tumor 
of  the  Rectum;  Polypus  of  the  Rectum;  Fistula;  Chronic  Ulceration; 
Stricture;  Cancer;  Atony;  Anal  Tumors  and  Excrescences;  Prurigo  Ani. 

Congenital  Imperfections  of  the  Anus  and  Rectum. — These  may 
be  classed  as  follows: — 1.  Imperforate  anus,  without  deficiency  of  the 
rectum.  2.  Imperforate  anus,  the  rectum  being  partially  or  wholly  defi- 
cient. 3.  Anus  opening  into  a  cul-de-sac,  the  rectum  being  partially  or 
wholly  deficient.  4.  Imperforate  anus  in  the  male,  the  rectum  being  par- 
tially or  wholly  deficient,  the  bowel  communicating  with  the  urethra  or 
neck  of  the  bladder.  5.  Imperforate  anus  in  the  female,  the  rectum  being 
partially  deficient,  and  communicating  with  the  vagina  or  uterus.  6.  Im- 
perforate anus,  the  rectum  being  partially  deficient,  and  opening  exter- 
nally in  an  abnormal  situation  by  a  narrow  outlet.  7.  Narrowness  of  tha 
anus.  A  few  other  congenital  deviations  have  been  observed,  but  they 
are  of  very  rare  occurrence,  the  seven  forms  enumerated  above  being  those 
most  commonly  met  with. 

The  classification  of  these  imperfections  is  founded  on  states  which  can 
generally  be  recognized  during  life.  Unfortunately  the  condition  of  the 
terminal  portion  of  the  intestinal  canal,  and  its  relations  to  the  parts  around, 
cannot  be  predicated  with  any  certainty.  In  cases  of  imperforate  anus,, 
or  of  anus  opening  into  a  cid-de-sac,  the  intestinal  canal  may  terminate  in 
a  blind  pouch  at  the  brim  of  the  pelvis,  the  rectum  being  wholly  wanting; 
or  an  imperfect  rectum  may  form  a  shut  sac,  descending  to  the  floor  of  the 
pelvis,  or  as  low  as  the  neck  of  the  bladder  in  the  male,  or  the  commence- 
ment of  the  vagina  in  the  female.  It  is  known  that  the  anal  portion  of 
the  bowel  is  developed  distinctly  from  the  upper  portion,  and  that  the  two 
afterwards  approximate  and  unite,  the  diaphragm  or  septum  disappearing 
9 


130         DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

by  interstitial  absorption.  A  failure  in  this  process  is  the  cause  of  the  sec- 
ond form  of  congenital  imperfection.  The  cases  of  imperforate  anus  in 
which  the  rectum  communicates  with  the  urethra  or  vagina  depend  on  the 
original  existence  of  a  cloaca,  the  malformation  being  due  to  an  incom- 
plete separation  during  foetal  life.  These  conditions  are  the  result  of  an 
arrest  of  development  at  different  stages.  The  blind  pouch  in  which  the 
intestinal  canal  terminates  is  sometimes  connected  to  the  anal  integument, 
or  to  the  anal  cul-de-sac,  by  a  cord  prolonged  from  the  bowel  above.  These 
cases  are  not,  like  the  preceding,  the  result  of  a  non-formation  of  the  rec- 
tum, but  are  produced  by  an  obliteration  of  the  bowel,  which  was  origin- 
ally well  formed;  the  obliteration  being  a  pathological  change  due  proba- 
bly to  ulceration  and  adhesion  which  had  taken  place  during  intra-uterine 
life. 

These  imperfections  of  the  rectum  can  be  remedied  only  by  operative 
measures  which  vary  according  to  the  nature  of  the  irregularity;  and  this 
treatment  unfortunately  often  fails  in  ootaining  a  vent  for  the  fgeces,  or 
in  securing  a  permanent  and  suflBcient  passage.  In  cases  of  failure  m 
reaching  the  bowel  at  the  natural  site,  life  may  still  be  preserved  by  mak- 
ing an  artificial  anus  either  in  the  left  loin  or  in  the  left  groin.  For  sev- 
eral reasons  the  latter  is  the  best  situation  for  the  operation  in  infants.' 

HEMORRHOIDS. — The  haemorrhoidal  veins  distributed  in  the  sub-mucous 
tissue  at  the  lower  part  of  the  rectum  communicate  in  loops,  and  form  a 
plexus  which  surrounds  the  bowel  just  within  the  internal  sphincter.  The 
veins  are  best  seen  when  somewhat  congested,  their  deep  purple  hue  being 
very  apparent  through  the  thin  mucous  membrane  with  which  they  are  in 
close  contact.  The  plexus  is  then  found  to  be  about  three-quarters  of  an 
inch  in  length,  and  composed  of  veins  of  various  sizes,  arranged  for  the 
most  part  lengthwise  and  in  clusters,  being  especially  collected  in  the 
longitudinal  folds  of  the  rectum.  The  plexus  does  not  extend  lower  than 
the  external  sphincter,  but  veins  branching  from  it  pass  between  the  fibres 
of  the  internal  sphincter,  and  descend  along  the  outer  edge  of  the  former 
muscle  close  to  the  integuments  surrounding  the  anus. 

These  veins  are  very  liable  to  become  dilated  and  varicose,  giving  rise 
to  the  disease  termed  hcBrnorrhoids  or  piles.  When  the  plexus  beneath 
the  mucous  membrane  is  thus  affected,  the  haemorrhoids  are  said  to  be 
internal.  When  the  veins  beneath  the  integuments  outside  the  muscle 
are  enlarged,  the  haemorrhoids  are  called  external.  Both  external  and 
internal  piles  very  frequently  co-exist. 

We  may  distinguish  two  kinds  of  external  piles.  1.  A  sanguineous 
tumor.  2.  A  cutaneous  excrescence  or  growth.  The  sanguineous  tumor 
consists  of  a  softish  elevation  of  the  skin  near  the  margin  of  the  anus  of 
a  rounded  fonp,  and  of  a  livid  or  slightly  blue  tinge.  On  cutting  into  it 
we  find  a  dark-colored  coagulum  enclosed  in  a  cyst.  This  kind  of  pile  is 
generally  single,  and  seated  at  the  side  of  the  anus,  but  a  second  may 
form  at  a  subsequent  period.  The  second  form  of  external  pile  consists 
of  flattened  prolongations  of  skin.  They  are  generally  the  chronic  results 
of  the  first  form,  a  projecting  fold  left  after  absorption  of  the  coagulum 
having  undergone  further  growth.  The  cutaneous  excrescence  contains 
no  clot,  and  no  enlarged  or  varicose  veins;  but  clots  and  dilated  veins  may 
often  be  found  at  its  base.  There  is  sometimes  only  a  single  broad  flat 
excrescence  at  the  side  of  the  anus;  but  there  are  often  two,  one  on  each 
side,  and  occasionally  more.     Similar  excrescences  occur  as  the  result  of 

'  See  "  Observation*  on  the  Rectum,"  by  Mr.  Curling.    3(1  edit  p.  221. 


DISEASES   OF   THE   RECTUM   AND   ANUS.  131 

imtating  discharges  from  the  bowel,  and  are  common  in  stricture  and  ul« 
ceration  of  the  rectum. 

The  changes  in  structure  consequent  upon  internal  haemorrhoids  vary 
a  good  deal.  In  general  the  lower  veins  of  the  hasmorrhoidal  plexus  are 
dilated  irregularly,  or  into  pouches,  which  are  filled  with  dark  compact 
coagula.  A  bunch  of  varicose  veins  crowded  in  the  lower  ends  of  the 
longitudinal  folds  produce  prominent  projections  of  the  mucous  mem- 
brane, and  deepen  the  pouches  between  the  folds.  Two  or  three  of  these 
prominences  unite  so  as  to  form  a  transverse  fold  just  within  the  sphincter. 
After  a  time  the  mucous  membrane  and  sub-mucous  tissue  become  greatly 
hypertrophied.  Thus  are  developed  elongated  processes  of  a  polypus  form, 
and  projecting  transverse  folds.  The  arteries,  which  are  abundantly  sup- 
plied to  the  lower  part  of  the  rectum,  enlarge  considerably,  so  that  the 
mucous  membrane  involved  is  not  only  thickened,  but  extremely  vascular. 
Such  are  the  changes  found  in  dissection,  but  the  description  conveys  only 
a  faint  and  incomplete  impression  of  the  condition  of  the  parts  observed 
during  life. 

Internal  piles  seldom  attract  attention  until  they  have  become  devel- 
oped so  as  to  protrude  at  the  anus  in  defecation.  They  then  exhibit  a  re- 
markable diversity  of  appearance  according  to  their  number,  size,  and  con- 
dition. The  protrusion  may  consist  of  only  one  good-sized  pile,  found 
usually  towards  the  perinaeum  or  front  of  the  anus.  A  single  pile,  con- 
sisting of  a  bright  red  projecting  membrane  connected  with  a  loose  fold 
of  integument,  and  readily  extruded,  often  forms  in  young  persons,  espe- 
cially women.  More  commonly,  there  are  three  distinct  prominent  growths 
differing  in  size,  one  at  each  side  of  th^  anus,  and  a  third  in  front;  the  lat- 
ter, the  perineal,  being  the  largest.  In  old-standing  cases  they  may  be 
more  numerous.  The  distinction  between  the  piles  is  commonly  well- 
marked,  but  not  always;  for  the  piles  sometimes  merge  into  each  other, 
the  protrusion  forming  a  circular  prominence.  The  aspect  of  extruded 
piles  depends  much  upon  their  condition,  whether  congested,  inflamed,  or 
constricted  by  the  sphincter.  In  a  relaxed  condition  of  the  sphincter, 
they  form  softish  tumors  of  a  red  granular  appearance;  but  when  pro- 
truded and  congested,  they  constitute  large  tense  tumid  swellings  of  a 
deep  red  color  and  smooth  surface,  which  readily  bleed.  When  haemor- 
rhoids of  large  size  are  fully  protruded,  the  integuments  at  the  margin  of 
the  anus  become  everted,  and  form  a  broad  band  girting  the  base  of  the 
tumors  externally. 

External  and  internal  piles  often  co-exist,  the  sphincter  forming  a  nar- 
row band  separating  the  two.  But  the  two  forms  may  merge  into  each 
other,  the  difference  being  recognized  by  the  character  of  the  covering, 
mucous  membrane  or  skin,  the  line  of  junction  being  visible  on  the  sur- 
face of  the  tumors.  Internal  piles  are  confined  to  the  lower  border  of  the 
rectum.  They  never  occur,  as  has  been  asserted,  higher  up  the  bowel,  so 
that  when  they  are  entirely  removed  there  is  very  little  liability  to  a  re- 
currence of  the  disease. 

Haemorrhoids  is  a  disease  of  middle  and  advanced  age.  They  rarely 
occur  before  puberty,  and  but  few  persons  in  after-life  altogether  escape 
them.  All  those  circumstances  which  determine  blood  to  the  rectum,  or 
which  impede  its  return  from  the  pelvis,  tend  to  produce  this  disease.  In 
many  persons  there  is  a  natural  predisposition  to  haemorrhoids,  and  this 
may  be  hereditary.  The  complaint,  indeed,  often  occurs  in  members  of 
the  same  family  who  inherit  the  local  weakness  of  their  parents.  But  a 
predisposition  is  more  frequently  acquired  by  sedentary  habits,   indul- 


132         DISEASES   OP  THE   INTESTINES   AND   PERITONEUM. 

gences  at  table,  and  excitement  of  the  sexual  organs,  which  explains  the 
well-known  circumstance  that  haemorrhoids  are  more  prevalent  in  the 
higher  classes  of  society  than  amongst  the  laboring  population.  The  lat- 
ter take  plenty  of  exercise,  live  a  good  deal  in  the  open  air,  and  are  little 
liable  to  constipated  bowels.  Haemorrhoids,  though  common  in  both 
sexes,  occur  more  frequently  in  males  than  females.  Few  women  bear 
children  without  becoming  in  some  degree  a£fected  by  them;  but  the  uri- 
nary and  genital  disorders  of  the  other  sex,  combined  with  freer  habits  of 
living,  are  still  more  fertile  sources  of  piles. 

The  symptoms  produced  by  haemorrhoids  vary  a  good  deal  in  different 
subjects,  and  in  different  stages  of  the  complaint.  External  piles  cause  a 
feeling  of  heat  and  tingling  at  the  anus.  A  costive  motion  is  followed  by 
a  burning  sensation,  and  the  excrescence  becomes  slightly  swollen  and  ten- 
der on  pressure,  so  as  to  render  sitting  uneasy.  This  congested  state  of 
the  pile  may  subside,  or  it  may  lead  to  inflammation  and  considerable  en- 
largement of  the  haemorrhoid,  which  then  forms  an  oval  tumor,  red,  tense, 
and  extremely  tender.  The  irritation  produced  by  costive  evacuations,  or 
by  friction  in  sitting  and  cleansing  the  part,  sometimes  gives  rise  to  ulcer- 
ation on  the  inner  surface  of  the  pile,  causing  a  sore  which  extends  a  lit- 
tle within  the  circle  of  the  sphincter.  This  is  liable  to  occur  particularly 
to  those  growths  at  the  margin  of  the  anus  which  hold  a  middle  place  be- 
tween internal  and  external  piles.  The  pain  in  these  cases  is  rather  se- 
vere, being  a  burning  sensation  lasting  for  some  time  after  defecation. 

Internal  piles,  when  slight,  may  exist  for  years,  causing  little  incon- 
venience besides  slight  bleeding  after  a  costive  motion,  and  occasionally 
a  feeling  of  fulness,  heat,  and  itching,  just  inside  the  anus.  When  small 
they  protrude  slightly  with  the  mucous  membrane  in  defecation,  returning 
afterwards  within  the  sphincter.  When  of  larger  size,  they  always  pro- 
trude at  stool,  and  require  to  be  replaced,  the  patient  usually  pushing 
them  up  with  his  fingers.  In  a  lax  state  of  the  sphincters,  and  a  loose 
and  hypertrophied  condition  of  the  mucous  membrane  from  which  they 
spring,  piles  come  down,  even  when  the  patient  stands  or  walks  about. 
When  thus  exposed  to  view  they  appear  very  prominent,  of  a  rounded 
form,  and  often  of  a  deep  purple  or  violet  hue,  have  a  soft  feel,  and  are 
evidently  very  vascular,  bleeding  readily  when  handled.  If  free  from  con- 
gestion, they  exhibit  a  florid  red  color,  with  a  rough,  granular  surface. 
In  consequence  of  the  friction  and  pressure  to  which  they  are  exposed, 
their  mucous  surface  becomes  abraded,  and  furnishes  a  mucous  discharge 
tinged  with  blood  which  soils  the  linen.  They  are  often  so  sore  that  the 
patient  is  obliged  to  lie  down,  sitting  causing  great  uneasiness. 

Persons  frequently  suffer  no  inconvenience  from  piles  until,  irritated 
by  a  costive  motion,  smart  purgation,  or  the  excitement  of  wine,  they 
become  congested  and  inflamed,  and  cause  spasm  of  the  sphincter  muscle. 
Patients  then  have  what  is  termed  an  "attack  of  piles" — that  is  to  say, 
they  suddenly  experience  a  sensation  of  heat,  weight,  and  fulness  just 
within  the  rectum,  followed  by  considerable  pain  at  stool,  and  sometimes 
irritation  about  the  bladder.  Piles  in  this  state  are  liable  to  be  strangu- 
lated and  constricted  by  the  external  sphincter,  and  haemorrhoids  of  large 
size  have  been  known  to  slough  off,  the  patients  being  relieved  of  the  com- 
plaint by  a  sort  of  natural  process,  after  much  pain  and  suffering.  In 
general  the  extremities  only  of  one  or  two  of  the  larger  haemorrhoids 
perish,  and  the  patient,  though  experiencing  relief,  is  by  no  means  cured 
of  the  complaint. 

One  of  the  most  common  symptoms  of  internal  haemorrhoids,  indeed, 


DISEASES   OF   THE   RECTUM    AND   ANUS.  133 

that  from  which  the  name  of  the  complaint  is  derived,  is  h.'cmorrhag'e, 
which  occurs  when  the  bowels  are  evacuated.  The  bleeding'  varies 
greatly  in  amount.  Sometimes  the  motions  are  merely  tinged  with  a  few 
drops  of  blood;  in  other  instances  the  quantity  lost  is  considerable,  several 
ounces  being  voided  at  stool.  The  bleeding  may  be  irregular,  occurring 
only  after  costive  motions,  or  in  certain  states  of  health;  or  it  may  take 
place  daily,  going  on  even  within  the  bowel,  and  producing  the  usual 
symptoms  of  derangement  from  continued  losses  of  blood.  The  complex- 
ion becomes  blanched,  and  the  lips  appear  waxy.  The  patient  loses  flesh 
and  strength,  has  a  quick  and  small  pulse,  sulTers  from  throbbings  in  the 
temples,  palpitations  and  difficulty  of  breathing  on  making  any  exertion, 
and  at  length  the  legs  and  feet  become  (edematous.  The  character  of  the 
bleeding  also  varies;  it  is  sometimes  venous,  sometimes  arterial.  There 
are  persons  who  are  liable  to  discharges  of  blood  from  the  haemorrhoidal 
veins  either  at  regular  periods  or  when  from  good  living  or  want  of  exer- 
cise the  habit  is  fuller  than  usual.  In  these  cases  from  three  to  six  ounces 
of  blood,  or  even  more,  pass  away  at  stool,  following  the  evacuation,  and 
the  blood  which  is  voided  is  of  a  dark  color  and  evidently  venous.  Such 
discharges  must  not  be  rashly  interfered  with.  I  had  under  my  care,  a 
gentleman,  seventy  years  of  age,  who  had  been  subject  to  haemorrhoidal 
discharges  for  many  years,  usually  in  the  spring  and  autumn.  After 
lasting  a  week  or  ten  days  they  generally  ceased,  but  not  always,  and 
when  faint  and  weak  from  their  continuance,  he  was  in  the  habit  of  ar- 
resting them  with  cold-water  injections.  The  discharges  at  length  ceased, 
but  in  six  months  afterwards  his  urine  became  albuminous,  and  a  year 
later  he  died  suddenly  after  an  attack  of  epistaxis.  Periodical  losses  of 
this  character  relieve  congestion  of  the  liver  and  kidneys,  help  to  ward  off 
attacks  of  gout,  and  prevent  fits  of  apoplexy,  so  that  in  many  persons 
they  are  rightly  regarded  as  safety-valves.  Persons  who  suffer  from  in- 
ternal piles  sometimes  experience  a  pretty  copious  discharge  of  blood  from 
the  rectum.  The  bleeding  shortly  ceases,  and  all  uneasy  symptoms  sub- 
side. This  hsemorrhage  is  also  venous.  The  escape  of  blood  unloads  the 
congested  parts  and  the  patient  gets  relieved.  But  the  bleeding  which 
most  commonly  occurs  from  internal  piles  is  undoubtedly  arterial,  taking 
place  from  arteries  enlarged  by  disease.  The  vessels  on  the  spongy  sur- 
face of  the  mucous  membrane  readily  give  way  when  blood  is  determined 
to  the  part  in  defecation  or  when  abraded  by  the  passage  of  hard  faeces. 
An  artery  of  some  size,  exposed  by  ulceration,  continues  to  pour  out  blood, 
weakening  the  patient,  and  giving  rise  to  the  symptoms  above  described. 
Sometimes  a  small  artery  on  the  prominent  part  of  a  protruded  pile  may 
be  observed  pumping  out  blood.  That  haemorrhage  of  this  character  is 
good  for  the  health  is  quite  a  mistaken  notion,  and  it  is  important  that 
the  practitioner  should  distinguish  the  bleeding  taking  place  as  a  conse- 
quence of  local  disease  from  that  which  arises  from  a  constitutional 
plethora  or  congestion  of  tlie  intestinal  organs. 

When  piles  are  small,  and  cause  but  little  inconvenience,  the  treatment 
is  very  simple.  In  all  cases  attention  should  be  paid  t(S  the  habits  of 
living.  Persons  with  this  complaint  should  take  wine  in  great  moderation, 
if  at  all,  and  they  are  in  most  instances  benefited  by  abstaining  entirely 
from  stimulating  drinks.  Many  individuals  never  suffer  from  piles,  except 
after  taking  a  glass  of  spirits  and  water,  or  a  few  glasses  of  wine.  Such 
persons  should  become  rigid  water-drinkers.  Active  exercise  in  the  open 
air  should  be  taken  daily,  and  the  patient  should  avoid  sitting  too  long  at 
the  desk,  because  it  is  by  prolonged  sedentary  occupation  and  neglect  of 


134         DISEASES   OF   THE   INTESTINES    AND   PERITONEITM. 

the  rules  of  health  that  hfemorrhoid  complaints  are  induced,  which  explains 
why  literary  persons  so  often  suffer  from  them.  Chairs  with  cane  seats 
are  to  be  recommended.  The  bowels  must  be  carefully  regulated,  so  as 
to  avoid  hard  and  costive  motions,  as  well  as  frequent  actions.  Irritating 
the  rectum  by  repeated  purging  is  more  hurtful  even  than  constipation. 
On  the  other  hand,  when  the  liver  is  congested,  or  its  secretions  are  slug- 
gish, and  when  the  bowels  are  costive,  a  mild  cathartic,  by  clearing  the 
intestines,  especially  the  large,  unloads  the  congested  vessels  and  relieves 
the  piles.  Lenitive  electuary,  rendered  more  active  when  necessary  by 
the  addition  of  the  tartrate  of  potash,  will  probably  answer  the  purpose. 
The  foreign  mineral  waters,  the  PttUna  or  the  Friedrichshall,  taken  in  the 
morning,  fasting,  agree  well  with  many  patients,  and  ensure  a  comfortable 
relief.  When  the  intestines  require  fully  unloading,  a  draught  containing 
rhubarb  powder  and  the  tartrate  or  sulphate  of  potash  answers  without 
producing  local  irritation.  Half  a  pint  of  cold  spring  water  thrown 
into  the  rectum  in  the  morning  after  breakfast  has  a  very  beneficial  effect 
on  the  haemorrhoids  by  constringing  the  vessels  and  softening  the  motions 
before  the  usual  evacuation.  The  relief  afforded  by  this  treatment,  com- 
bined with  care  in  the  mode  of  living,  is  often  remarkable.  Ordinary 
venous  bleeding  may  be  stopped  in  this  way,  using  iced  water,  or  some 
astringent  such  as  a  solution  of  tannic  acid  or  infusion  of  rhatany.  When 
the  bleeding  is  of  an  arterial  character,  astringent  injections  are  not  so 
successful,  and  operative  treatment  often  becomes  necessary.  When 
there  is  a  slight  slimy  discharge  from  the  surface  of  an  exposed  internal 
pile,  benefit  may  be  derived  from  the  application  of  mild  citrine  ointment 
or  the  application  of  the  solid  sulphate  of  copper  to  the  part. 

External  piles,  when  large  and  troublesome,  and  internal,  when  of 
such  a  size  as  to  protrude  at  stool,  and  to  be  subject  to  inflammation, 
ulceration,  and  frequent  bleeding,  can  be  removed  only  by  operation. 

Prolapsus  op  the  Rectum. — In  describing  the  changes  occurring 
in  piles,  it  was  remarked  that  internal  haemorrhoids  slip  down  and  project 
at  the  anus.  The  descent  of  these  growths  is  often  attended  with  more 
or  less  eversion  of  the  hypertrophied  mucous  membrane  of  the  lower  part 
of  the  rectum.  In  relaxed  states  also  of  the  sphincter  muscle  and  coats 
of  the  bowel,  loose  folds  of  mucous  membrane  are  liable  to  protrude  and 
to  require  replacement.  This  protrusion  and  exposure  of  the  thickened 
mucous  membrane  with  or  without  internal  haemorrhoids  has  been  erro- 
neously described  by  writers  as  prolapsus  of  the  rectum.  In  the  true 
prolapsus,  however,  there  is  a  great  deal  more  than  an  eversion  of  the 
internal  surface  of  the  bowel.  The  gut  is  inverted;  there  is  a  "falling 
down  "  and  protrusion  of  the  whole  of  the  coats — a  change  in  many  re- 
spects analogous  to  intussusception,  but  differing  from  it  in  the  circum- 
stances that  the  involved  intestine,  instead  of  being  sheathed  or  invagin- 
ated,  is  uncovered  and  projects  externally. 

The  length  of  bowel  protruded  in  prolapsus  varies  greatly,  from  an 
inch  to  six  inches  or  even  more.  The  shape  and  appearance  of  the  swell- 
ing depend  partly  upon  its  size,  and  partly  upon  the  condition  of  the 
external  sphincter.  When  not  of  any  great  length,  the  protrusion  forms 
a  rounded  swelling  which  overlaps  the  anus,  at  which  part  it  is  contracted 
into  a  sort  of  neck.  In  its  centre  there  is  a  circular  opening,  communi- 
cating with  the  intestinal  canal.  An  inversion  of  greater  extent  usually 
forms  an  elongated  pyriform  tumor,  the  free  extremity  of  which  is  often 
tilted  forwards  or  to  one  side,  and  the  intestinal  aperture  assumes  the 
form  of  a  fissure  receding  from  the  surface  of  the  tumor,  owing  to  t\u 


DISEASES    OF   THE    llECTUM    AND    ANUS.  135 

traction  exerted  upon  it  by  the  meso-rectum.  In  a  relaxed  state  of  the 
sphincter  the  surface  of  the  protrusion  has  the  usual  florid  appearance  of 
the  mucous  membrane;  but  in  other  cases  it  is  of  a  violet  or  livid  color, 
and  tumid  from  congestion,  the  return  of  blood  being  impeded  by  the 
contracted  sphincter.  The  exposed  mucous  membrane  is  often  thickened 
and  granular,  and  sometimes  ulcerated  from  friction  against  the  thighs 
and  clothes.  A  thin  film  of  lymph  may  be  occasionally  observed  coating 
its  surface.  On  examining  the  section  of  a  large  prolapsed  rectum  from 
a  child,  I  found  the  coats  of  the  protruded  bowel  greatly  enlarged;  the 
areolar  tissue  was  infiltrated  with  an  albuminous  deposit,  the  muscular 
tunic  hypertrophied,  and  the  mucous  membrane  much  thickened  and 
dense  in  structure,  especially  at  the  free  extremity  of  the  protrusion. 
These  changes  account  for  the  difficulty  in  reducing  the  parts,  and  in 
retaining  them  afterwards,  so  often  experienced  in  the  treatment  of  this 
complaint  in  children,  the  bowel  having  become  too  large  to  be  conve- 
niently lodged  in  its  natural  position,  and,  like  a  foreign  body,  exciting 
the  actions  of  expulsion.  The  atonic  and  relaxed  state  of  the  sphincter 
muscle  in  these  cases  is  well  shown  by  the  facility  with  which  one  or  two 
fingers  can  be  passed  through  the  anus  even  in  children. 

Prolapsus  of  the  rectum  is  observed  most  frequently  in  children 
between  the  ages  of  two  and  four,  but  is  liable  to  occur  at  a  later  period 
of  life.  In  infancy  it  is  produced  by  protracted  diarrhcea;  the  frequent 
forcing  of  stool  so  weakening  the  coats  and  connections  of  the  rectum, 
and  relaxing  the  sphincter,  as  at  length  to  lead  to  inversion  of  the  bowel. 
The  straining  efforts  to  pass  water  consequent  upon  stone  in  the  bladder 
often  give  rise  to  prolapsus  in  early  life.  In  adults  the  descent  results 
chiefly  from  a  weakened  condition  of  the  sphincter  and  levator  ani  mus- 
cles, and  a  general  relaxation  of  the  tissues  of  the  part.  The  rectum 
being  imperfectly  supported  by  the  perinaeum,  the  eversion  at  stool  grad- 
ually extends  until  an  actual  inversion  takes  place,  and  this  may  increase 
until  it  forms  a  protrusion  of  considerable  size.  Prolapsus  in  adults  is 
more  common  in  women  than  in  men.  In  the  former  it  results  in  a  great 
measure  from  weakness  in  the  parts  consequent  upon  child-bearing. 

The  annoyance  and  inconvenience  occasioned  by  a  prolapsus  of  the 
rectum  vary  considerably  under  different  circumstances.  Thus  the  bowel 
may  descend  only  in  a  very  slight  degree  at  stool,  and  disappear  by  a 
natural  effort  afterwards,  or  it  may  come  down  only  occasionally,  admit« 
ting  of  being  easily  thrust  back,  and,  when  returned,  will  remain  in  its 
place  until  an  attack  of  diarrhoea  or  the  effort  to  pass  a  costive  motion 
causes  it  to  fall  again.  Prolapsus  sometimes  occurs  after  every  motion, 
and  even  when  the  patient  stands  or  moves  about,  forming  a  large  red 
unsightly  tumor  exposed  to  friction,  feeling  sore,  soiling  the  linen  with  a 
bloody  discharge,  and  required  to  be  pushed  back  frequently  during  the 
day.  Or  the  gut  may  be  constantly  protruded,  being  fixed  so  as  not  to 
admit  of  replacement.  There  are  cases  on  record  in  which  a  prolapsed 
bowel  has  become  strangulated  and  inflamed,  and  has  even  mortified  aud 
sloughed  off,  similar  to  what  sometimes  happens  to  an  invaginated  intes- 
tine. 

Young  persons  generally  outgrow  this  complaint  by  the  period  of 
puberty;  and  common  as  is  prolapsus  in  early  life,  it  is  rather  rare  m 
grown-up  subjects.  I  have  known,  however,  of  persons,  who  have  had 
this  disease  in  childhood,  and  lost  it,  becoming  affected  with  a  return  of 
it  in  after-life  from  the  effects  of  a  diarrlioea.  In  adults  prolapsus  is  com- 
monly attended  with  a  slimy  discharge  of  mucus  tinged  wi+h  HlonrJ    "-n^^ 


136  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

in  some  instances,  with  troublesome  bleeding.  The  haemorrhage  does  not 
occur  from  any  particular  spot,  but  as  an  exudation  from  the  congested 
mucous  surface  when  the  bowel  is  protruded  at  stool.  As  the  cause 
producing  the  bleeding  is  constantly  recurring,  there  is  sometimes  consid- 
erable dilHculty  in  arresting  it,  local  applications  having  little  effect  so 
long  as  the  bowel  continues  to  descend. 

In  children,  irritability  of  the  bowels  and  diarrhoea  must  be  checked 
and  disordered  secretions  corrected  by  suitable  remedies.  Attention  must 
be  paid  to  diet,  and  when  the  powers  are  feeble  benefit  will  be  derived 
from  quinine  or  steel.  In  slight  cases  it  will  be  sufficient  to  direct  the 
nurse,  when  the  rectum  comes  down  at  stool,  to  place  the  child  on  its 
face  across  her  lap,  and  to  return  the  parts  by  taking  a  soft  cambric 
handkerchief  or  sponge  wetted  in  cold  water,  in  both  hands,  and  by  gentle 
but  steady  compression  to  push  the  protruded  gut  back  into  the  pelvis. 
The  relaxed  state  of  the  membrane  may  be  corrected  by  administering 
regularly  every  evening  an  astringent  injection,  such  as  the  decoction  of 
oak  bark  with  alum,  the  infusion  of  rhatany,  or  the  muriated  tincture  of 
iron  diluted.  The  child  should  also  be  kept  at  rest  in  bed,  and  be  made 
to  relieve  its  bowels  in  the  recumbent  posture  until  the  strong  tendency 
to  prolapsus  has  been  corrected.  The  chief  difficulty  is  to  retain  the  parts 
after  they  have  been  reduced.  A  piece  of  sponge  or  cotton  wool,  moist- 
ened in  an  astringent  lotion,  may  be  lodged  at  the  anus  and  secured  there 
by  approximating  the  buttocks  by  means  of  a  broad  strip  of  adhesive 
plaster  applied  across  from  one  side  to  the  other,  and  further  secured  with 
a  T  bandage.  When  the  surface  of  the  prolapsed  bowel  is  ulcerated,  it 
should  be  painted  with  a  solution  of  nitrate  of  silver.  In  cases  of  stone, 
the  prolapsus  generally  disappears  after  lithotomy. 

Prolapsus  in  the  adult  requires  surgical  treatment  to  contract  the 
opening  of  the  anus  by  escharotics  or  operation.  In  old  and  unhealthy 
subjects  the  trouble  may  be  remedied  by  a  well-fitted  rectum  supporter. 

Irritable  Ulcer  axd  Fissure. — The  mucous  membrane  of  the  lower 
part  of  the  rectum  is  arranged  in  longitudinal  folds,  which  disappear  in 
the  expanded  state  of  the  bowel.  These  folds  terminate  below  at  the  ex- 
ternal sphincter.  Just  within  this  structure  and  betv/een  the  folds,  the 
mucous  membrane  is  slightly  dilated,  variously  in  different  subjects,  but 
in  many  to  such  an  extent  as  to  form  small  sacs  or  pouches.  Beside  these 
folds,  and  in  the  spaces  between  them,  there  is  a  series  of  short  projecting 
columnar  processes,  about  three-eighths  of  an  inch  in  length,  separated  by 
furrows  or  sinuses  more  or  less  deep,  which  are  arranged  around  the  lower 

f)art  of  the  rectum.  In  the  evacuation  of  the  rectum,  foreign  bodies  or 
ittle  masses  of  hardened  fa?ces  are  liable  to  be  caught  or  detained  in  the 
pouches  just  described.  It  is  in  these  little  sinuses  thus  exposed  to  irrita- 
tion, abrasion,  and  rent,  that  a  superficial  circumscribed  ulcer  is  formed. 
On  examining  the  ulcer  without  distending  the  rectum,  the  lateral  edges 
only  being  presented  to  view,  the  breach  of  surface  has  the  appearance  of 
&Ji«fture — the  term  commonly  given,  but  improperly,  to  the  sore,  which 
though  often  originating  in  a  rent  is  obviously  more  than  a  mere  cleft  or 
fissure  in  the  mucous  membrane  of  the  bowel.  Such  an  ulcer  may  occur 
in  any  part  of  the  lower  circumference  of  the  rectum,  but  is  usually  found 
at  the  back  part..  It  is  quite  superficial,  and  though  sometimes  circular  is 
generally  of  an  oval  shape,  its  long  axis  being  longitudinal  and  its  lower 
extremity  extending  within  the  circle  of  the  extended  sphincter.  On 
tactile  examination  the  breach  of  surface  and  size  of  the  sore  can  be  read- 
ily distinguished.     "With  the  speculum,  the  ulcer  being  fully  exposed  ia 


DISEASES   OF   THE    RECTUM    AND    ANUS.  137 

clearly  seen  not  to  be  a  mere  fissure  but  a  superficial  sore.  The  surface 
is  of  a  brighter  red  than  the  surrounding'  membrane,  and  has  the  usual 
indented  appearance  of  an  ulcer.  A  small  pedunculated  pile  or  polypoid 
growth,  attached  to  the  opposite  side  of  the  bowel,  is  frequently  found  in 
these  cases.  The  growth  lodges  in  the  ulcer,  adding  to  the  irritation  and 
the  difficulty  of  cure. 

The  amount  of  suffering  produced  by  this  superficial  ulcer  varies  a 
good  deal,  but  the  sore  is  generally  extremely  sensitive,  and  occasions 
severe  distress.  It  is  so  situated  that  the  fjeces,  in  their  passage  out- 
wards, rub  over  its  surface,  and  the  painful  contact  excites  spasm  of  the 
sphincter  muscle,  causing  a  sharp  burning  pain,  and  often  a  forcing  sensa- 
tion, which  lasts  for  two  or  three  hours,  the  distress  being  usually  greater 
after  defecation  than  during  the  act;  and  in  some  instances,  an  interval, 
varying  from  five  to  ten  minutes  or  more,  elapses  between  the  evacua- 
tion and  the  occurrence  of  pain.  The  pain  is  sometimes  so  acute  that 
patients  resist  the  desire  to  pass  motions,  and  allow  the  bowels  to  become 
costive  in  dread  of  the  sufferings  brought  on  by  evacuating  them.  I  have 
known  persons  to  deprive  themselves  of  food  in  order  to  avoid  an  action. 
In  one  case,  the  intensity  of  suffering  led  the  patient  to  adopt  the  danger- 
ous course  of  inhaling  chloroform  whilst  sitting  on  the  close  stool,  and  he 
could  not  be  persuaded  to  go  to  the  closet  without  this  remedy. 

The  irritable  ulcer  occurs  usually  in  middle  life,  and  is  more  frequent 
in  women  than  in  men.  It  is  met  with  as  often  in  single  as  in  married 
women.  Though  the  symptoms  are  characteristic,  the  sore  is  often  over- 
looked. On  the  attempt  to  separate  the  margins  of  the  anus,  or  to  dilate 
the  sphincter  to  get  a  view  of  the  ulcer  or  even  to  introduce  the  finger, 
spasm  with  an  aggravation  of  pain  is,  in  most  cases,  immediately  excited, 
and  tjie  orifice  becomes  strongly  contracted,  and  forcibly  drawn  in.  When 
this  is  the  case,  it  is  better  to  desist,  and  to  get  an  assistant  to  administer 
chloroform.  Under  its  influence  the  sphincter  yields  completely,  and  the 
practitioner  is  able  to  ascertain  the  exact  seat,  character,  and  extent  of 
the  ulcer.  In  cases  free  from  spasm,  a  good  view  may  be  obtained  by 
simply  dilating  the  anus  with  the  two  forefingers  or  by  introducing  a 
speculum. 

The  irritable  ulcer  seldom  heals  under  the  influence  of  local  applica- 
tions. The  treatment  necessary  is  an  incision  through  its  centre,  includ- 
ing the  superficial  fibres  of  the  sphincter  muscle,  in  order  to  place  this 
muscle  at  rest,  to  enlarge  the  passage  and  displace  the  sore;  thus  remov- 
ing those  sources  of  irritation  which  prevent  its  healing.  An  incision  is 
not  invariably  required;  but  in  all  cases  in  which  the  pain  is  considerable, 
and  in  which  there  is  much  spasm  of  the  sphincter,  the  attempt  to  pro- 
cure the  healing  of  the  sore  by  local  applications  so  often  protracts  the 
patient's  sufferings,  and  so  constantly  ends  in  failure,  that  it  is  not  desira- 
ble to  make  it.  In  cases  complicated  with  a  pedunculated  pile  or  polypus, 
this  growth  must  also  be  excised.  When  the  suffering  is  moderate,  a  cure 
may  be  attempted  by  giving  a  laxative  to  ensure  soft  evacuations,  rest  in 
the  recumbent  posture,  and  the  application  of  mercurial  ointment  with 
morphia,  belladonna,  or  chloroform. 

Irritable  Spiiixcter  Muscle. — Persons  occasionally  suffer  pain  in 
defecation,  especially  during  solid  motions,  increasing  afterwards,  and  last- 
ing half  an  hour  or  an  hour.  It  is  described  as  a  forcing  sensation,  or  a 
feeling  as  if  the  bowel  were  unrelieved.  The  anus  is  strongly  contracted 
and  drawn  in  by  the  action  of  the  sphincter.  Any  attempt  to  examine  the 
part  induces  spasm;  and  the  finger  passed  through  it  is  tightly  grasped  by 


138         DISEASES   OF  THE  INTE3TIKES   AND   PERITONEUM. 

the  muscle,  as  if  girt  by  a  cord.  In  cases  of  old  standing,  the  muscle  be- 
comes hypertrophied  and  forms  a  mass,  encircling  the  finger  like  a  thick 
unyielding  ring.  This  irritability  and  hypertrophy  of  the  sphincter  some- 
times produces  serious  trouble  in  defecation,  owing  to  the  expulsive  pow- 
ers of  the  bowel  being  insufficient  to  overcome  the  impediment  caused  by 
this  muscle  to  the  passage  of  the  faeces. 

Irritability  of  the  sphincter  occurs  commonly  in  hysterical  females,  or 
in  nervous  susceptible  women,  who  are  accustomed  to  watch  and  to  inten- 
sify every  sensation.  The  treatment  required  is  mild  laxatives,  the  local 
application  of  an  ointment  containing  chloroform,  opium,  or  belladonna, 
and  the  occasional  passage  of  a  bougie  coated  with  a  sedative  ointment. 
The  bougie  gives  great  relief  in  those  cases  in  which  an  irritable  sphincter 
offers  resistance  to  the  passage  of  the  faeces.  In  obstinate  cases  a  partial 
or  complete  division  of  the  sphincter  may  be  necessary  to  remove  the 
difficulty. 

Nervous  Affections  of  the  Rectum. — The  symptoms  as  well  as  the 
causes  of  these  complaints  are  usually  obscure,  and  the  diagnosis  is  often 
perplexing.  On  analyzing  the  symptoms,  they  appear  to  consist,  in  some 
instances,  in  an  irritability,  or  a  too  frequent  inclination  to  relieve  the 
bowels;  in  others,  in  a  morbid  sensibility  or  undue  tenderness  of  the  part; 
and  more  rarely  in  an  exaltation  of  sensibility  independent  of  contact, 
constituting  neuralgia. 

1.  Irritable  Rectum. — In  derangements  of  the  alimentary  canal,  and  of 
the  organs  connected  with  it,  the  fasces  are  often  unhealthy  and  irritating 
to  the  mucous  membrane;  consequently  when  passed  into  the  rectum  they 
excite  uneasiness,  with  an  urgent  desire  to  void  them.  Pressing  and  pain- 
ful calls  are  also  experienced  when  the  bowel  is  ulcerated  and  in  other 
ways  diseased.  In  "  the  irritable  rectum  "  there  is  an  inclination,  more  or 
less  urgent,  to  empty  the  bowel,  usually  at  inconvenient  times,  although 
the  mucous  membrane,  as  well  as  the  faeces,  are  healthy,  and  often  when 
there  is  little  or  nothing  to  expel.  Thus,  a  country  rector  experienced  an 
urgent  desire  to  relieve  the  rectum  in  church,  just  before  and  during  the 
performance  of  divine  service,  notwithstanding  an  effort  in  the  closet  had 
just  previously  proved  ineffectual.  He  was  subject  to  it  also  when  attend- 
ing public  meetings  and  whilst  riding  in  a  railway  carriage.  Persons  liv- 
ing in  the  country  and  going  daily  to  business  by  railway  are  sometimes 
annoyed  by  a  desire  to  go  to  the  closet  just  as  the  train  is  coming  up,  and 
during  the  journey  to  town,  but  it  passes  off  as  soon  as  they  arrive  at  the 
counting-house  and  get  engaged  in  business.  The  complaint  is  often  con- 
nected with  an  anxious  fidgety  state  of  mind,  against  which  patients  may 
often  successfully  struggle.  Sly  patient,  the  rector,  got  relief  from  a  gen- 
tle aperient  on  the  Saturday,  and  a  mild  opiate  suppository  administered 
on  Sunday  morning. 

2.  Morbid  Sensibility  of  Rectum. — Several  cases  have  fallen  under  my 
notice  in  which  uneasiness  has  been  experienced  at  a  particular  spot  in  the 
rectum,  being  complained  of,  chiefly,  during  or  after  defecation.  The  fixity 
and  sometimes  severity  of  the  pain,  and  its  aggravation  from  pressure,  have 
naturally  led  to  the  suspicion  of  the  existence  of  some  lesion  in  the  mucous 
membrane,  such  as  an  ulcer:  but  on  careful  examination,  no  breach  of  sur- 
face has  been  discovered;  nothing  has  been  observed  except  in  some  in- 
stances slight  elevations  and  increased  redness  and  vascularity  at  the  spot 
affected,  and  occasionally  abrasion  of  the  mucous  membrane.     The  com- 

Elaint  consists  chiefly  in  an  exalted  sensibility  of  the  nerves  of  the  part, 
ut  the  alterations  in  appearance  just  described  indicate  that  there  is  also 


DISEASES   OF  THE   RECTUM   AND   ANUS.  139 

Bome  slight  and  superficial  structural  change.  The  remedies  for  the  com- 
plaint are  chiefly  local.  Sedatives,  such  as  opium  and  belladonna,  passed 
into  the  rectum  give  relief,  but  more  permanent  benefit  may  be  derived 
from  applications  calculated  to  alter  the  character  of  the  part,  such  as  the 
sulphate  of  copper  or  a  strong  solution  of  the  nitrate  of  silver  applied 
through  a  speculum.  I  have  in  several  instances  cured  severe  morbid 
sensibility  in  this  part  by  two  or  three  caustic  applications. 

3.  Neuralgia  of  the  Kectum. — The  two  forms  of  nervous  affection 
already  described  would  be  included  by  some  writers  under  the  general 
term  of  neuralgia,  the  sensibility  of  the  rectum  being  in  a  measure  per- 
verted or  augmented;  but  it  will  be  remarked,  that  in  the  first  no  actual 
pain  is  experienced — there  is  merely  an  irregular  and  often  causeless 
desire  to  evacuate  the  part;  while  in  the  second,  the  uneasiness  consequent 
upon  the  augmented  sensibility  is  either  produced  or  aggravated  by  fric- 
tion and  pressure.  In  true  neuralgia  of  the  rectum,  the  pain  is  severe, 
but  quite  independent  of  contact.  There  is  no  tenderness.  In  the  cases 
of  neuralgia  which  have  fallen  under  my  notice,  the  pain  was  not  char- 
acterized by  paroxysms,  by  a  suddenness  of  attack  and  disappearance,  or 
by  any  regular  intermittence,  nor  was  the  pain  of  an  acute  kind,  but  it 
was  described  as  a  continuous  enduring  pain,  or  a  constant  gnawing  sen- 
sation, sufficiently  severe  to  interfere  seriously  with  the  comforts  and  even 
the  business  of  life.  The  pain  was  in  no  degree  mental,  for  the  patients 
were  not  persons  of  an  anxious  nervous  temperament,  and,  unlike  the  two 
other  forms  of  nervous  affection,  occupation  and  amusement  had  little  in- 
fluence in  mitigating  their  troubles.  The  remedies  calculated  to  g^ve 
relief  are  such  as  are  useful  in  neuralgia  elsewhere,  as  quinine,  steel,  arsenic, 
bromide  of  potassium,  local  sedatives,  and  hypodermic  injections,  and  they 
are  as  uncertain  in  removing  the  affection  of  the  rectum  as  in  curing  neu- 
ralgia of  other  parts. 

In  some  instances  it  is  impossible  to  refer  nervous  complaints  of  the 
rectum  to  either  of  the  forms  just  described,  morbid  sensibility  and  neu- 
ralgia being  so  combined  as  to  prevent  any  distinction  being  drawn. 

Villous  Tumor  of  the  Rectum. — A  growth  similar  to  the  villous 
tumor  which  occurs  in  the  bladder  and  on  other  mucous  surfaces  sometimes 
forms  in  the  rectum.  It  was  first  described  by  Mr.  Quain  under  the  name 
of  a  "  peculiar  bleeding  tumor  of  the  rectum;  "  but  as  it  closely  resembles 
the  outgrowths  found  in  the  bladder  called  villous,  I  prefer  the  latter 
term.  The  tumor  springs  from  the  mucous  membrane  generally  by  a 
broad  base,  is  soft  in  structure,  and  composed  of  a  number  of  projecting 
papillae  or  villi.  On  minute  examination  it  is  found  to  vary  in  structure 
according  to  the  proportion  of  the  fibrous  or  vascular  elements  entering 
into  its  composition.  The  villous  tumor  is  innocent  in  character,  and  is 
not  apt  to  return  after  complete  removal.  Its  chief  peculiarity  in  the 
rectum  as  in  the  bladder  is  a  remarkable  disposition  to  bleed.  This  growth 
is  a  rare  disease,  and  occurs  only  in  adults.  When  it  projects  at  the  anus, 
it  exhibits  characteristic  projecting  processes  of  a  deep  red  color. 

The  b'eeding  to  which  this  growth  gives  rise  and  the  slimy  discharge 
render  its  removal  very  necessary.  If  the  tumor  be  attached  high  up,  and 
a  ligature  can  be  applied  round  its  base,  this  is  desirable,  as  it  would  be 
difficult  to  arrest  bleeding  after  excision. 

Polypus  of  the  Rectum  occurs  in  two  forms — the  soft  or  follicidnr^ 
and  the  hard  orfhrous.  The  soft  polypus  forms  generally  in  early  life. 
Its  essential  element  is  a  considerable  agglomeration  of  elongated  follicles. 
There  is  a  network  of  small  vessels  on  its  surface  which  is  also  furnished 


140  DISEASES    OF   THE   INTESTIITES    AND   PERITONEUM. 

with  papillae.  The  polypus  is  attached  to  the  mucous  membrane  of  the 
rectum  by  a  narrow  peduncle  which  varies  in  length.  The  polypus  is  gen- 
erally single,  but  several  have  sometimes  been  found.  The  follicular 
polvpus  usually  makes  its  appearance  external  to  the  anus  in  children 
after  a  stool,  and  it  resembles  a  small  strawberry,  being  of  a  soft  texture, 
granular  on  its  surface,  and  of  a  red  color.  It  produces  no  suffering,  but 
causes  usually  a  slight  bloody  discharge,  which,  occurring  after  every 
motion,  excites  attention.  In  some  instances  the  bleeding  is  sufficient 
to  weaken  the  patient.  The  description  of  the  complaint  by  the 
mother  or  nurse  is  apt  to  mislead  the  practitioner  and  to  induce  him  to 
conclude  that  the  case  is  common  prolapsus.  The  growth  can  generally 
be  detected  by  the  finger  passed  into  the  bowel;  and  when  the  peduncle 
is  long  enough,  the  tumor  is  forced  out  at  stool,  and  its  nature  can  then 
be  ascertained  without  difficulty.  The  follicular  polypus  occurs  very  rarely 
in  the  adult. 

The  treatment  of  polypus  in  children  is  very  simple  and  always  effectual. 
The  tumor  should  be  strangulated  by  a  ligature  secured  around  the  pedicle 
and  then  returned  within  the  bowel.  This  causes  no  pain,  and  the  polypus 
comes  away  with  the  motions  two  or  three  days  afterwards.  Excision  is 
not  quite  safe,  as  it  is  liable  to  be  followed  by  bleeding. 

The  fibrous  polypus  is  of  a  pear  shape,  with  a  peduncle  more  or  less 
long  and  thick.  It  varies  in  firmness,  seldom  bleeds,  but  occasions  a  slight 
mucous  discharge;  and  when  the  peduncle  is  long,  or  the  tumor  low  down, 
it  protrudes  at  the  anus  after  stool,  and  requires  replacement.  When 
lodged  within  the  bowel,  it  causes  a  sensation  of  unrelief,  as  if  a  foreign 
body  or  feculent  lump  required  discharge.  The  polypoid  growth  some- 
times becomes  congested,  and  when  protruded  in  this  state  its  peduncle  is 
liable  to  become  girt  by  the  sphincter,  which  causes  great  pain.  The  suf- 
fering is  still  greater  when,  as  frequently  happens,  the  polypoid  growth  is 
complicated  with  an  ulcer  within  the  circle  of  the  sphincter.  The  polypus, 
coming  in  contact  with  the  ulcer,  irritates  it,  and  prevents  its  healing. 

The  polypus  must  be  removed  by  ligature  or  excision;  and  if  an  ulcer 
also  exists,  it  must  be  divided  at  the  same  time. 

Fistula. — The  loose  areolar  tissue  around  the  lower  part  of  the  rectum 
is  occasionally  the  seat  of  abscess,  which  bursts  externally  near  the  anus. 
But  instead  of  the  part  healing  afterwards  like  abscesses  in  other  situa- 
tions, the  walls  contract  and  become  fistulous,  and  the  patient  is  annoyed 
by  a  discharge  from  the  opening.  Such  is  the  complaint  termed  ^fistula 
in  ano.  The  abscess  giving  rise  to  fistula  sometimes  forms  with  all  the 
characters  and  symptoms  of  acute  phlegmon,  suppuration  taking  place 
early,  and  the  matter  coming  quickly  to  the  surface.  But  more  frequently 
a  thickening  appears  at  a  spot  near  the  anus  with  scarcely  any  sign  of  in- 
flammation, and  but  little  local  pain,  and  is  gradually  resolved  into  a  fluc- 
tuating swelling,  which  being  opened  discharges  a  fetid  pus.  On  intro- 
ducing a  probe  at  the  external  orifice  of  a  fistula  formed  in  either  way,  it 
may  pass  through  a  small  opening  in  the  coats  of  the  rectum  into  the 
bowel;  the  case  is  then  called  a  complete  fistula.  When  there  is  no  in- 
ternal opening,  the  complaint  is  named  blind  external  fistula.  The  external 
orifice  is  usually  but  a  short  distance  from  the  anus,  its  situation  being 
often  indicated  by  a  button-like  growth,  and  it  is  in  the  centre  of  this  red 
projecting  granulation  that  the  opening  is  found.  The  aperture,  how- 
ever, is  not  always  so  marked,  and  being  very  small — a  mere  slit  concealed 
in  the  folds  of  the  anus — it  cannot  be  detected  without  careful  search. 
The  abscess,  before  breaking  or  being  opened,  may  have  burrowed  to  some 


DISEASES   OP  THE   RECTUM   AND   ANUS.  141 

distance,  and  the  external  orifice  may  then  be  placed  two  or  three  inches 
from  the  anus  in  the  direction  of  the  buttock  or  perinaeum.  An  abscess 
may  make  its  way  into  the  bowel  before  bursting  externally,  but  the  inner 
opening  is  generally  formed  after  the  external,  and  is  small  in  size.  The 
sinus  burrows  close  to  the  mucous  membrane  of  the  rectum,  which  forms 
a  thin  barrier  between  the  bowel  and  the  sinus.  Ulceration  ensues  at  one 
point,  and  thus  is  formed  the  internal  orifice  of  the  fistula.  The  orifice  is 
most  commonly  just  within  the  sphincter:  a  fact  established  some  years 
ago  by  M.  Ribes,  and  fully  confirmed  by  later  observation.  The  inner 
opening,  however,  sometimes  forms  higher  up  the  rectum,  as  I  have  clearly 
ascertained  both  in  the  living  and  dead  subjects.  Ulceration  of  the 
mucous  membrane,  from  the  wound  of  a  fish  bone  or  from  other  causes, 
may  perforate  the  bowel  just  within  the  sphincter,  and,  allowing  the  escape 
of  feculent  matter  into  the  areolar  tissue  around,  may  give  rise  to  abscess 
and  fistula.  Fistula  occurs  in  phthisical  subjects,  originating  in  tubercular 
ulceration  of  the  mucous  membrane  and  perforation  of  the  bowel.  In 
these  cases  the  inner  orifice  is  usually  large  in  size,  and  there  is  sometimes 
a  second  opening.  Though  the  inner  orifice  is  most  commonly  found  just 
within  the  sphincter,  the  fistula  itself  often  extends  some  distance  up  the 
side  of  the  rectum,  as  far  as  two  or  three  inches,  or  even  higher,  and  it 
may  burrow  in  different  directions.  When  the  sinuses  are  tortuous,  or 
pass  in  different  directions,  there  may  be  more  than  one  inner  opening. 
Sometimes  there  is  an  external  orifice  on  each  side  of  the  anus  leading  to 
fistulous  passages  which  pass  to  the  back  of  the  rectum,  and  communicate 
with  the  gut  at  this  part  by  a  single  orifice,  so  as  to  form  a  sort  of  horse- 
shoe fistula.  The  matter  is  liable  to  lodge  in  these  complicated  sinuses, 
to  give  rise  to  inflammation,  and  to  lead  to  fresh  abscesses  and  additional 
fistulous  passages.  In  old-standing  cases,  the  walls  of  the  fistulous  passages 
become  dense  and  callous,  feeling  gristly  to  the  finger.  In  all  cases  of 
complete  fistula  the  occasional  escape  of  a  little  feculent  matter  into  the 
passage  is  amply  sufficient  to  prevent  the  part  healing,  even  if  the  actions 
of  the  levator  and  sphincter  ani  and  the  movements  of  defecation  did  not 
also  interfere.  Authors  have  described  blind  internal fisttila,  in  which  an 
opening  into  the  bowel  leads  to  a  fistula  without  any  external  orifice. 
Such  cases  are  rarely  met  with.  The  external  opening  sometimes  closes 
for  a  short  time,  the  spot  being  indicated  by  redness  and  induration ;  but 
sooner  or  later  it  re-opens,  and  the  discharge  returns,  or  a  fresh  opening, 
is  made  at  some  distance  off.  It  may  happen,  however,  that  the  original 
ulcerated  opening  in  the  rectum  being  large,  the  matter  from  the  abscess 
in  the  areolar  tissue  outside  finds  its  way  so  readily  into  the  bowel  that 
the  abscess  does  not  burrow  towards  the  surface.  The  situation  of  the 
suppurating  cavity  may  be  ascertained  externally  by  a  sort  of  hollow  or 
indistinct  fluctuating  feel.  A  bistoury  plunged  into  this  will  render  the 
fistula  complete.  A  blind  internal  fistula  is  very  liable  to  be  overlooked. 
I  have  met  with  several  instances  in  which  this  has  happened.  In  one 
case,  the  discharge,  which  was  abundant  and  kept  the  linen  constantly 
soiled,  was  supposed  to  proceed  from  |he  vagina. 

An  anal  fistula  is  at  all  times  an  annoying  complaint.  Even  when  the 
seat  of  the  disease  is  free  from  all  inflanmiation  and  tenderness,  the 
patient  is  troubled  with  a  discharge  Avhich  stains  the  linen  and  keeps  the 
part  uncomfortably  moist.  The  discharge  is  usually  a  thin  purulent 
fluid;  at  other  times  it  is  thick,  and  in  complete  fistula  tinged  browc 
from  admixture  of  feculent  matter.  The  discharge  is  more  or  less 
copious  in  different  cases,  and  varies  also  at  different  times.     It  occa- 


142         DISEASES    OF   THE   INTESTINES    AND    PERITONEgM. 

sionally  becomes  so  thin  and  scanty  that  the  patient  supposes  the  fistula 
is  about  to  close,  when  he  is  disappointed  by  fresh  irritation  being  set  up, 
and  the  complaint  becoming  as  annoying  as  ever. 

Anal  fistula  is  a  disease  of  middle  life,  and  occurs  more  frequently  in 
men  than  in  women.  It  is  occasionally  met  with  in  young  children,  but 
rarely  forms  in  advanced  life,  owing  partly  to  the  laxity  of  the  rectum 
and  sphincter  in  old  people  rendering  the  mucous  membrane  less  liable  to 
irritation  and  injury,  and  partly  to  the  relief  obtained  by  discharges  from 
the  haemorrhoidal  veins  when  congested. 

The  treatment  necessary  during  the  formation  of  the  abscess,  which 
precedes  the  establishment  of  a  fistula,  is  rest  in  the  recumbent  posture, 
fomentations  or  the  hip-bath,  a  poultice  to  the  part,  and  mild  laxatives. 
As  soon  as  fluctuation  can  be  felt,  the  prominent  or  central  part  should 
be  punctured  freely  to  prevent  the  matter  burrowing  in  the  loose  areolar 
tissue,  and  thus  to  limit  the  extension  of  the  sinuses.  Fomentations  and 
poultices  must  be  continued  until  inflammation  has  subsided  and  the  sup- 
purating sac  has  become  fistulous  and  indolent.  An  examination  may 
then  be  made.  This,  as  well  as  the  cure  of  anal  fistula  by  operation,  is 
entirely  surgical. 

Chronic  Ulcebation  op  the  Rectum. — The  rectum  is  subject  to 
ulceration  in  dysentery  and  other  diseases,  the  mucous  membrane  being 
destroyed  to  a  greater  or  less  extent.  Chronic  ulcers  of  a  tubercular 
character  also  occur  in  this  part,  but  they  are  generally  small  in  size. 
Several  cases  of  ulceration  in  the  rectum,  the  origin  of  which  must  be 
ascribed  to  syphilis,  have  fallen  under  my  notice,  and  this  symptom  is 
probably  less  rare  than  is  commonly  supposed.  Syphilitic  ulcers  are 
usually  large  in  size,  and  often  involve  the  deeper  structures  of  the  coats 
of  the  rectum,  so  that  the  healing  process  is  very  apt  to  cause  a  serious 
contraction  of  the  passage. 

The  chief  symptoms  referable  to  chronic  ulceration  of  the  rectum  are — 
a  purulent  discharge  from  the  anus  more  or  less  copious;  motions  gener- 
ally loose  and  mixed  or  coated  with  a  slimy  fluid,  and  streaked  with  blood; 
soreness  in  passing  stools  and  occasionally  tenesmus.  The  pain  in  defeca- 
tion varies  considerably,  being  in  some  cases  severe,  in  others  very  slight. 
Indeed,  it  is  surprising  how  little  suffering  is  often  caused  by  the  actions 
of  the  rectum  and  passage  of  the  fasces  in  cases  of  large  ulceration  of  the 
mucous  surface.  The  suffering  much  depends  on  the  position  of  the 
ulcer.  Whether  it  be  large  or  small,  if  it  extends  low  down,  so  as  to  • 
come  within  the  grasp  of  the  sphincter  muscle,  the  pain  is  generally 
severe  and  persistent  after  defecation,  and,  in  addition  to  other  treatment, 
an  incision  through  the  lower  margin  of  the  ulcer  is  often  required  to 
release  it  from  the  actions  of  the  sphincter. 

The  character,  position,  and  extent  of  chronic  ulceration  in  the  rec- 
tum must  he  ascertained  by  examination  with  the  finger  and  with  the 
speculum,  -The  surgeon  will  be  able  to  feel  a  rough,  uneven  surface, 
more  or  less  indented  or  depressed,  and  frequently  hardness  and  consoli- 
dation of  the  walls  of  the  rectum. »  The  appearance  of  the  sore  in  the 
lower  ])art  of  the  bowel  may  be  seen  through  a  glass  speculum  with  an 
open  end  made  oblique  and  large.  This  instrument  is  also  very  useful  for 
the  application  of  local  remedies. 

The  treatment  suitable  to  chronic  ulceration  greatly  depends  on  the 
nature  and  extent  of  the  disease,  and  upon  the  constitutional  condition 
of  the  patient.  In  severe  cases,  I  always  keep  the  patient  at  rest  in  the 
recuui'uent  position.     In  extensive  destruction  of  the  mucous  surface  with 


DISEASES   OF   THE    RECTUM   AND   ANUS.  lib 

relaxed  and  copious  discharges,  especially  when  the  disease  originates  in 
dysentery,  vegetable  astringents,  such  as  simaruba,  krameria,  and  bael, 
combined  with  the  mineral  acids  and  opium,  are  generally  of  great  ser- 
vice in  restraining  the  tenesmus  and  irritating  evacuations  and  discharges. 
The  subnitrate  of  bismuth  with  magnesia  and  anodynes  often  affords  groat 
relief.  In  many  cases  sulphate  of  copper  with  opium  may  be  given  wiih 
advantage.  When  the  ulceration  is  consequent  on  syphilis  or  scrofula, 
the  remedies  appropriate  to  these  diseases  are  required.  The  diet  must 
be  carefully  regulated.  The  local  treatment  consists  in  the  repeated 
application  of  weak  solutions  of  nitrate  of  silver,  and  anodyne  injections 
with  mucilage,  or  anodyne  suppositories. 

Stricture  of  the  Rectum. — The  rectum,  like  other  mucous  canals, 
as  the  oesophagus  and  urethra,  is  liable  to  obstruction  from  contraction 
of  its  walls,  forming  the  disease  caUed  stricticre.  The  contraction  may  be 
very  limited  in  extent,  and  the  stricture  is  then  termed  atimdarj  or  the 
contraction  may  include  a  portion,  more  or  less  considerable,  of  the 
bowel.  The  sub-mucous  tissue  is  the  chief  seat  of  disease,  and  is  con- 
densed and  converted  into  close-set  fibrous  tissue.  The  thickening  of  the 
coats  of  the  bowel  may  be  confined  to  part  only  of  its  circumference,  or 
may  be  greater  on  one  side  than  on  the  other,  contracting  the  canal 
irregularly  and  forming  a  winding  passage;  or  the  induration,  instead  of 
being  limited  to  a  small  portion  of  the  bowel,  may  involve  the  greater 
part  of  the  whole  of  the  gut.  The  peritoneum  investing  the  contracted 
bowel  generally  retains  its  healthy  structure  and  appearance.  Above  the 
stricture  the  rectum  is  usually  dilated  and  thickened.  The  enlargement 
results,  not  from  a  yielding  of  the  intestine,  but  from  a  general  hypertro- 
phy of  the  walls  of  the  bowel,  and  particularly  of  the  muscular  coat.  The 
mucous  membrane  at  this  part  is  rarely  healthy.  It  is  red  and  tumid,  or 
eroded  and  ulcerated,  the  diseased  surface  supplying  during  life  a  puru- 
lent discharge.  There  are  often  ulcerated  apertures  leading  to  fistulous 
passages  which  extend  for  some  distance  and  open  externally  near  the 
anus  or  in  the  buttock.  The  bowel  below  the  stricture  is  generally  more 
or  less  diseased,  and  frequently  studded  with  small  excrescences  arising 
from  partial  hypertrophies  or  irregular  growths  of  the  surface  and  folds 
of  the  mucous  membrane.  These  excrescences  tend  to  narrow  the  canal 
below  the  stricture. 

The  seat  of  stricture  in  the  rectum  is  at  about  an  inch  and  a  half  to 
two  inches  from  the  anus,  and  easily  within  reach  of  the  finger.  In 
twenty-eight  cases  I  found  the  stricture  at  this  distance  in  twenty-one. 
In  two  in  was  nearer  the  anus,  and  in  five  at  a  greater  distance.  In  three 
of  the  latter  the  stricture  was  at  the  point  where  the  sigmoid  flexure 
terminates  in  the  rectum.  In  two  instances  I  have  met  with  double 
stricture. 

The  pathological  changes  causing  stricture  originate  in  chronic  inflam- 
mation of  the  mucous  and  sub-mucous  areolar  tissue  of  the  rectum.  It  is 
seldom  possible  to  fix  on  the  exciting  cause,  but  it  is  well  known  that  the 
part  is  exposed  to  numerous  sources  of  irritation.  Women,  in  whom  the 
disease  is  much  more  common  than  in  men,  have  sometimes  ascribed  its 
oiigin  to  a  difficult  labor,  by  which  no  doubt  the  bowel  may  be  injured, 
so  as  to  set  up  chronic  disease.  In  twenty  cases  of  women  with  stricture 
of  the  rectum  1  ascertained  that  the  disease  commenced  shortly  after  a 
labor,  and  in  some  instances  was  attributed  to  an  injury  at  that  time. 
Injuries  such  as  a  kick,  and  violent  use  of  an  enema  tube,  have  also  been 
known  to  give  rise  to  stricture.     Strictures  sometimes  originate  in  tiie 


144  DISEASES   OF   THE   INTESTINES    AND   PERITONEUM, 

contraction  consequent  upon  the  healing  of  ulcers  or  wounds  in  the  bowel, 
more  commonly  indeed  than  is  generally  supposed.  In  extensive  dysen- 
teric and  syphilitic  ulceration  of  the  lower  bowel  the  passage  is  liable  to 
become  seriously  contracted  in  this  way.  I  have  met  with  several  cases 
of  stricture  of  this  kind.'  The  rectum  may  also  be  obstructed  by  an  out- 
growth of  fat,  or  by  an  infiltration  of  fat  in  the  coats  of  the  bowel.  This 
IS  a  very  rare  form  of  stricture.  There  is  a  specimen  of  it  in  the  Museum 
of  St.  Thomas's  Hospital,  and  Mr.  Worthington  has  related  a  case  in  tht 
Transactions  of  the  Pathological  Society  (vol.  xv.).  In  the  Museum  o> 
the  London  Hospital  also  there  is  a  large  fibrous  and  fatty  tumor  devel- 
oped outside  the  rectum  and  contracting  the  passage. 

Stricture  of  the  rectum  is  a  disease  of  middle  life,  being  seldom  met 
with  in  young  persons  except  as  a  consequence  of  some  injury.  It  is  rare 
also  in  old  people.  The  disease  generally  occurs  between  the  ages  of 
twenty  and  fifty. 

The  earliest  symptom  of  stricture  is,  generally,  habitual  constipation 
with  difficult  defecation  when  the  motions  are  solid.  The  difficulty  being 
readily  removed  by  a  solvent  purgative,  the  nature  of  the  case  is  not 
usually  suspected  at  this  early  period.  As  the  contraction  increases,  the 
constipation  is  overcome  with  difficulty,  and  the  patient  acquires  the 
habit  of  straining.  The  stools  are  observed  to  be  small  in  calibre,  and 
are  often  voided  in  small  lumps.  The  mucous  surface,  irritated  by  the 
disturbance  in  the  functions  of  the  rectum,  becomes  inflamed  and  exco- 
riated. This  renders  the  action  of  the  bowels  painful,  a  burning  sensa- 
tion lasting  for  an  hour  or  more  after  stool.  There  is  also  a  secretion  of 
brown  slimy  mucus,  which  escapes  with  the  motions  and  soils  the  linen. 
The  gases  involved  in  the  intestines  not  escaping  readily,  give  rise  to 
flatulent  distention  of  the  abdomen,  especially  in  the  course  of  the  de- 
scending colon,  and  to  disagreeable  efforts  for  relief.  The  bowels  often 
remain  constipated  for  days  together,  and  then  a  spontaneous  mucous 
diarrhcEa,  excited  by  the  faecal  collection  or  by  a  strong  cathartic,  softens 
the  motions  and  enables  the  patient  to  void  the  accumulated  mass,  its 
passage  being  attended  with  pain.  In  other  instances,  the  patient  is 
teased  with  frequent  fluid  evacuations,  and  urgent  desires  to  pass  them. 
As  the  disease  makes  progress  and  ulceration  ensues,  the  discharges  be- 
come purulent  and  bloody,  and  the  sufferings  are  much  increased,  the 
passage  of  motions  being  likened  by  the  patient  to  a  feeling  as  if  boiling 
water  was  passing  through  the  rectum.  At  this  period,  pain  is  often  felt 
in  the  sacrum.  The  discharges  are  sometimes  so  copious  that  the  stric- 
ture is  overlooked,  the  case  being  mistaken  for  one  of  protracted  diarrhoea. 
Ulceration  often  leads  to  abscesses  and  fistula,  sinuses  in  the  buttocks 
and  labia  being  common  complications  of  old-standing  stricture  of  the 
rectum.  The  appetite  and  even  the  general  health  often  remain  good  for  a 
long  time.  The  disease  is  very  chronic;  and  so  long  as  a  passage  for  the  mo- 
tions can  be  obtained,  the  patient  continues  to  follow  his  avocations,  suf- 
fering more  or  less  at  different  periods.  The  derangement  of  the  diges- 
tive functions,  the  irritation  kept  up  by  the  disease,  and  the  exhausting 
discharges  from  the  lower  bowel  in  the  course  of  time  undermine  the  con- 
stitution and  bring  on  hectic  symptoms.  The  appetite  fails,  the  body 
emaciates,  profuse  night-sweats  ensue  and  the  stricture  directly  or  indi- 
rectly becomes  the  cause  of  death.  This  is  sometimes  hastened  by  a 
lodgment  of  hardened  faices,  or  of  some  foreign  body  just  above  the  stric- 

*  See  my  "  Observationa  on  Diseaaee  of  the  Eectum,"     Third  edition.     P.  119. 


DISEASES  OF  THE   BEGTUM   AND   ANUS.  145 

ture,  so  as  to  block  up  the  bowel  and  occasion  the  symptoms  of  internal 
obstruction.  Such  an  obstruction  is  sometimes  the  cause  of  an  examina> 
tion  of  the  rectum,  and  thus  leads  to  the  detection  of  a  close  stricture 
previously  unsuspected. 

In  order  to  detect  a  stricture  it  is  necessary  to  make  a  tactile  exami- 
nation. On  exposing  the  anus  small  flattened  excrescences  are  usually 
observed  at  the  margin  of  the  aperture.  These  cutaneous  growths  re- 
semble collapsed  external  piles,  except  that  they  are  redder  in  color,  and 
are  kept  moist  by  the  escape  of  a  thin  discharge  from  the  bowel.  Thev 
originate  in  the  irritation  kept  up  by  this  discharge.  The  finger,  well 
greased,  being  passed  carefully  and  gently  into  the  rectum,  will  be 
arrested  on  reaching  the  stricture,  so  that  the  point  only  can  enter.  If 
the  contraction  be  somewhat  recent  and  not  very  close,  the  finger  may 
be  carried  with  a  gentle  boring  motion  through  the  stricture  so  as  to  ex- 
amine its  whole  extent.  If  the  practitioner  encounters  much  resistance 
or  gives  much  pain,  he  must  not  venture  to  force  the  barrier,  but  must 
be  content  with  ascertaining  the  seat  and  degree  of  contraction.  In 
strictures  high  up  in  the  gut,  the  rectum  below  may  be  found  quite 
healthy,  but  it  is  often  dilated  and  baggy  with  weakened  expulsive 
powers.  In  strictures  low  down,  the  interior  of  the  rectum  is  often  abun- 
dantly studded  with  the  small  excrescences  which  I  have  described, 
which  communicate  to  the  finger  the  feeling  of  a  number  of  rough  irregu- 
lar eminences,  more  or  less  hard,  thickly  lining  the  surface.  This  condi- 
tion is  invariably  attended  with  a  profuse  discharge  from  the  bowel  of 
pus  and  slimy  matter  mixed  with  blood.  A  stricture  high  up  in  the 
rectum,  and  beyond  the  reach  of  the  finger,  is  sometimes  difficult  of  detec- 
tion. In  a  suspected  case  the  bowel  must  be  explored  by  a  flexible  in- 
strument. When  the  passage  is  free,  a  good-sized  flexible  gum  elastic 
tube  may  always  be  passed  into  the  colon.  The  point  is  apt  to  impinge 
on  the  sacrum,  or  to  be  caught  in  a  fold  of  the  bowel ;  but  if  some  warm 
fluid,  water  or  linseed-tea,  be  injected  somewhat  forcibly  through  the 
tube,  a  space  is  formed,  admitting  the  easy  transit  of  the  instrument.  In 
stricture,  pain  is  felt  when  an  instrument  reaches  the  point  of  contrac- 
tion, and  a  flexible  one  is  arrested  or  passed  on  with  more  or  less  diffi- 
culty. In  examinations  for  stricture  it  must  be  borne  in  mind  that  the 
rectum  is  liable  to  be  compressed  and  obstructed  by  disease  of  the  neigh- 
boring viscera — by  an  enlarged  or  retroflected  uterus,  fibrous  tumors  of 
this  organ,  a  distended  ovary,  an  excessively  hypertrophied  prostate, — an 
hydatid  tumor  between  the  laladder  and  rectum,  or  an  outgrowth  of  fat, 
such  as  I  have  described. 

The  main  object  in  the  treatment  of  a  stricture  in  the  rectum  is  to  re- 
move the  chronic  induration  and  to  dilate  the  contracted  part  sufficiently 
to  admit  a  free  passage  for  the  faeces.  The  dilatation  of  the  stricture  is 
to  be  effected  by  mechanical  means  —  by  the  passage  of  bougies,  and 
sometimes  by  operation  as  well.  The  treatment,  therefore,  is  chiefly  sur- 
gical. An  organic  stricture  fully  established  is  universally  admitted  to 
be  most  difficult  of  remedy,  and  several  high  authorities,  such  as  Dupuy- 
tren.  Dr.  Bushe,  and  Dr.  Colles  of  Dublin,  doubt  the  possibility  of  the 
disease  being  cured.  These  writers  have  undoubtedly  taken  too  unfavor- 1 
able  a  view  of  the  results  of  treatment.  In  addition  to  the  dilatation,  ■ 
means  must  be  adopted  to  relieve  the  irritability  of  the  part,  to  insure 
the  regular  passage  of  soft  evacuations.  An  opiate  suppository  or  injec- 
tion may  be  lodged  in  the  bowel  at  bed-time;  and  if  the  motions  are  cos- 
tive, some  confection  of  senna,  castor-oil,  or  PttUna  water  may  be  taken 
10 


146         DISEASES   OP  THE   INTESTINES  AND   PERITONEUM. 

in  the  morning,  in  doses  just  sufficient  to  obtain  an  action  of  the  bowels 
without  purging.  Castor-oil  is  often  of  great  service.  In  small  doses  it 
softens  the  feculent  masses,  and  lubricates  the  passage  without  weaken- 
ing the  patient.  Cod-liver  oil  is  also  an  excellent  remedy.  It  nourishes 
the  patient  and  softens  the  motions,  rendering  aperients  unnecessary. 
The  diet  should  be  nutritious,  and  consist  principally  of  animal  food,  so 
as  to  afford  a  small  amount  of  excrementitious  matter.  It  is  no  needless 
caution  to  advise  patients  to  be  careful  to  avoid  swallowing  plum-stones. 
Accumulations  in  the  bowel  above  the  stricture  may  be  prevented  by  the 
occasional  passage  of  an  elastic  tube  through  the  contraction  and  an  in- 
jection of  soap  and  water.  We  sometimes  meet,  especially  in  hospital 
practice,  with  old,  inveterate,  and  neglected  strictures,  in  which  the  dis- 
ease is  too  far  advanced  and  the  mischief  too  great  to  admit  of  relief  by 
dilatation.  In  such  cases,  when  the  sufferings  are  severe,  I  have  pro- 
posed the  operation  of  lumbar-colotomy,  and  have  performed  it  in  two 
cases.' 

Cancke  of  thb  Rectum. — The  coats  of  the  rectum  are  subject  to 
cancerous  degeneration  in  the  three  forms  of  scirrhous,  encephaloid,  and 
colloid.  The  disease  invades  the  coats  to  a  greater  or  less  extent,  pro- 
ducing contraction  of  the  canal,  and  it  is  liable  to  increase  until  it  narrows 
the  passage  to  such  an  extent  that  only  a  probe  can  pass  through  it. 
Fungoid  growths  sometimes  spring  from  the  mucous  membrane  at  the  side 
of  the  rectum  and  project  into  the  bowel.  Occasionally  the  bowel  becomes 
blocked  up  and  occluded  by  fungous  masses.  In  other  cases  the  changes 
which  ensue  have  a  contrary  effect,  degeneration  and  softening  causing 
the  coats  to  yield  and  increasing  the  calibre  of  the  canal.  A  description 
of  the  progress  of  cancer  of  the  rectum,  and  of  the  changes  that  occur  in 
the  advanced  stage,  is  a  description  of  the  disorganization  and  invasion  of 
all  the  tissues  of  the  part,  and  of  the  organs  in  its  immediate  neighbor- 
hood, in  various  degrees  in  different  cases.  In  some  instances  the  carci- 
nomatous bowel  becomes  wedged  in  the  pelvis,  agglutinated  and  fixed  to 
the  surrounding  parts,  forming  one  mass  of  disease.  Frequently  soften- 
ing and  ulceration  cause  fistulous  communications  with  neighboring  parts 
— with  the  vagina  in  the  female,  and  with  the  bladder  or  urethra  in  the 
male;  or  the  peritoneum  may  become  perforated  and  an  opening  made  into 
the  abdominal  cavity.  When  the  passage  is  contracted,  the  intestine 
above  becomes  dilated  and  hypertrophied  as  in  simple  stricture.  Carci- 
noma may  attack  any  part  of  the  bowel,  but  it  generally  affects  the  lower 
portion  within  three  inches  from  the  anus.  It  is  liable  to  occur  also, 
though  less  frequently,  at  the  point  where  the  sigmoid  flexure  terminates 
in  the  rectum.  The  disease  is  sometimes  limited  to  the  rectum  and  ad- 
joining parts,  though  the  lymphatic  glands  in  the  pelvis  and  lumbar  region 
often  become  affected,  the  liver  being  invaded  by  tubercles  and  the  peri- 
toneum also  studded  with  scirrhous  deposits. 

Cancer  of  the  rectum  generally  commences  insidiously.  Its  early 
symptoms  are  so  similar  to  those  of  simple  stricture,  that  the  nature  of 
the  disease  cannot  be  determined,  or  may  not  be  suspected,  until  a  con- 
siderable change  has  taken  place  in  the  condition  of  the  bowel.  The  patient 
is  troubled  with  flatulency,  has  difficulty  in  passing  his  motions,  and  strains 
in  the  effort  to  void  them;  and  as  the  disease  makes  progress,  he  experi- 
ences pains  about  the  sacrum,  which  gradually  increase  in  severity  and 
dart  down  the  limbs.     By  this  time  probably  some  alarm  is  excited,  and 

'  Vidt  London  Hospital  Reports,  vol.  iii. 


DISEASES   OF  THE   RECTUM   AND   ANUS.  147 

an  examination  may  be  called  for.  The  practitioner  on  introducing  his 
finger  into  the  rectum  may  easily  detect  a  contraction  more  or  less  rigid ; 
and  should  he  feel  any  irregular  nodules  about  the  stricture,  any  hard 
solid  tumor,  or  encounter  a  resistance  like  cartilage,  or  meet  with  softish 
tubercles  which  leave  a  bloody  mark  on  the  finger,  then  he  would  be  able 
to  decide  on  its  being  carcinomatous.  At  a  later  period  no  difficulty 
could  be  experienced.  There  is  a  hard  mass  of  disease  in  which  it  may  be 
difficult  to  discover  the  orifice  of  the  passage,  and  sometimes  round  fun- 
goid growths  which  bleed  readily  when  touched.  The  disease  may  extend 
as  low  as  the  anus.  An  irregular  red-looking  growth  sometimes  protrudes 
externally,  blocking  up  the  passage  or  displacing  the  anus.  The  stools 
become  relaxed  and  frequent  and  contain  blood,  and  in  passing  cause  a 
scalding  pain  and  give  rise  to  severe  suffering.  There  is  often  a  thin  of- 
fensive discharge,  and  as  the  disease  invades  the  sphincter,  incontinency 
ensues.  The  loss  of  retentive  power  is  often  a  great  trouble  in  cancer  of 
the  rectum.  This  arises  not  only  from  the  disease  invading  the  anus  and 
destroying  the  sphincter  muscle,  but  occurs  also  when  cancer  is  developed 
higher  up  in  the  bowel,  the  lower  part  being  free.  This  may  be  explained 
by  the  carcinomatous  disease  pressing  or  destroying  the  nerves  supplying 
the  sphincter  and  so  paralyzing  it.  The  sufferings  also  increase.  Severe 
shooting  pains  are  referred  to  the  groins,  back,  or  upper  part  of  the  sacrum, 
and  sometimes  extend  down  the  thighs  and  legs.  The  constitution  suffers 
in  due  course.  The  patient  acquires  the  blanched  sallow  look,  anxious 
countenance,  and  emaciated  appearan-oe  commonly  observed  in  persons 
suffering  from  malignant  disease.  If  complete  obstruction  does  not  accel- 
erate a  fatal  termination,  other  troubles  may  arise.  In  consequence  of  a 
communication  becoming  established  between  the  rectum  and  urethra  or 
bladder  in  males,  flatus  and  liquid  faeces  escape  from  the  urinary  passage, 
and  in  females  motions  are  discharged  from  the  vagina.  The  passage  of 
part  of  the  intestinal  contents  by  these  unnatural  channels  greatly  increases 
the  misery  of  the  patient's  condition,  rendering  him  an  object  of  disgust 
to  himself  and  offensive  to  those  about  him.  An  ulcerated  opening  into 
the  peritoneum,  allowing  the  escape  of  feculent  matter  into  the  abdomen, 
may  excite  peritonitis  and  thus  bring  the  case  to  a  fatal  termination;  or 
the  powers  of  life  gradually  giving  way,  the  patient  becomes  hectic  and 
exhausted,  worn  out  by  this  painful  and  distressing  malady.  There  is 
great  variety,  however,  in  the  degree  of  suffering,  and  even  of  constitu- 
tional derangement,  attending  the  disease.  Whilst  in  some  cases  the  suf- 
ferings are  excruciating,  in  others  they  are  comparatively  slight.  In  ray 
experience  patients  suffer  less  from  the  disease  when  developed  high  up 
in  the  rectum  than  when  formed  near  the  anus. 

Cancer  of  the  rectum  occurs  generally  in  midde  life.  The  earliest  age 
at  which  I  have  met  with  it  is  twenty,  the  patient  being  a  young  man  in 
the  London  Hospital.  It  is  commonly  believed  that  this  disease  attacks 
women  more  frequently  than  men.  This  does  not  accord  with  my  experi- 
ence of  cases  seen  in  hospital  and  private  practice.  Of  seventy-three 
cases  of  which  I  have  preserved  notes,  fifty-seven  were  males  and  sixteen 
females. 

All  that  can  be  obtained  from  remedies  is  palliation  of  the  symptoms, 
ease  from  pain,  and  support  under  the  wearing  effects  of  this  terrible  dis- 
ease. The  patient  should  remain  at  rest,  chiefly  iu  the  recumbent  posture, 
and  take  a  nourishing  but  not  stimulating  diet.  The  general  health  may 
be  supported  by  tonics.  The  bowels  must  be  kept  open  and  the  motions 
rendered  soft  by  Piillna  water  or  small  doses  of  castor-oil.     If  the  stricture 


148         DISEASES   OF   THE   INTESTINES   AND   PERITONEUM. 

be  close,  injections  may  be  necessary  through  a  long  tube  to  break  up 
the  feculent  masses.  The  greatest  care  is  necessary  in  the  passage  of  the 
tube,  as  if  force  be  used  the  carcinomatous  mass  may  yield  and  the  tube 
be  driven  into  the  abdomen.  Bleeding  may  be  checked  by  injections  of 
sulphate  of  copper  and  tannic  acid.  Pain  can  be  alleviated  by  opiate  and 
belladonna  injections,  or  by  small  doses  of  morphia  taken  night  and  morn- 
in<r,  their  strength  being  gradually  increased  as  the  effects  of  the  remedy 
diminish.  Subcutaneous  injections  of  morphia  also  are  effectual  in  giving 
relief.  So  great  were  the  sufferings  in  a  recent  case,  that  after  a  time  as 
much  as  3^  grs.  were  thus  injected  twice  a  day. 

In  cancerous  disease  of  the  rectum  attended  with  great  suffering  from 
incontinency  and  constant  scalding  discharges,  I  have  advocated  and  per- 
formed in  several  cases  colotomy  in  the  left  loin.  By  diverting  the  pas- 
sage of  the  faeces,  the  local  distress  can  be  in  a  great  measure  prevented, 
and  I  have  reason  to  believe  that  the  progress  of  the  disease  also  may  be 
retarded  by  the  removal  of  a  source  of  almost  continual  irritation.  I  have 
established  an  anus  in  the  left  loin  in  several  cases  of  cancer  in  which  no 
obstruction  existed,  in  order  to  mitigate  the  symptoms,  with  a  satisfactory 
result  in  prolonging  life  and  preventing  suffering.' 

Epithelial  Cancer  of  the  Anus  and  Rectum. — The  anus,  like 
other  parts,  where  a  junction  takes  place  between  the  skin  and  mucous 
membrane,  is  liable  to  epithelioma.  The  affection  is  comparatively  rare, 
and  has  seldom  been  noticed  by  writers.  It  is  easily  recognized  by  the 
ordinary  characters  of  the  sore.  In  the  few  cases  which  have  fallen  under 
my  notice,  the  disease  extended  into  the  rectum,  but  there  was  no  reason 
to  doubt  that  its  original  seat  was  the  anus.  The  only  treatment  applica- 
ble to  this  affection  is  caustics  or  excision.  I  prefer  the  latter,  as  more 
sure  and  thorough.  Though  more  common  at  the  anus,  epithelioma  may 
occur  in  any  part  of  the  mucous  membrane  of  the  rectum.  When  occur- 
ring up  the  bowel,  the  disease  is  apt  to  produce  slight  bleeding,  but  it  is 
much  less  serious  than  scirrhous  and  medullary  cancer.  The  latter  pro- 
duce sooner  or  later  some  contraction  or  obstruction  in  the  passage,  and 
show  a  tendency  to  involve  the  parts  around.  In  epithelial  cancer  I  have 
never  noticed  any  impediment  in  defecation,  and  have  invariably  found 
the  passage  free  and  unobstructed.  Neither  do  patients  complain  of  the 
distressing  pain,  referred  usually  to  the  sacrum,  which  persons  affected 
with  scirrhus  of  the  rectum  so  commonly  experience,  nor  suffer  painful 
tenesmus  and  defecation,  which  add  so  much  to  their  distress  in  this  form 
of  the  disease.  There  is  also  an  absence  of  the  cancerous  cachexia,  of  the 
emaciation  and  pale  and  anxious  countenance  so  frequently  remarked  in 
malignant  disease.  Epithelial  cancer  in  the  rectum  may  go  on  for  years, 
but  the  patient  becomes  exhausted  at  last  from  repeated  small  bleedings. 
The  hemorrhage  is  best  restrained  by  injections  of  solutions  of  sulphate 
of  copper,  chloride  of  zinc  or  tannin. 

Atony  of  the  Rectum. — In  paraplegia  the  forces  which  expel  the 
fjeces  and  the  retentive  functions  of  the  sphincter  are  both  destroyed; 
consequently,  the  motions,  if  sufficiently  liquid,  on  reaching  the  lower 
bowel  escape  involuntarily.  I  have  not  met  with  any  well-marked  case  of 
paralysis  of  the  rectum  independently  of  palsy  of  the  lower  half  of  the 
body;  but  several  instances  of  loss  of  tonicity  or  defective  muscular  power 
in  the  lower  bowel,  rendering  it  incapable  of  properly  extruding  its  con- 
tents, have  come  under  my  notice.     An  atonic  condition  of  the  rectum 

'  Vide  London  HoBpital  Reports,  vols,  ii  and  It. 


DISEASES   OP  THE   KECTUM   AND    ANUS.  149 

may  be  produced  by  the  too  free  and  frequent  use  of  enemata,  the  quan- 
tity thrown  up  being  so  large  as  to  dilate  the  bowel  and  impair  the  power 
of  its  muscular  coat.  This  condition  is  apt  to  give  rise  to  faecal  accumu- 
lations. Cases  of  this  kind  are  not  very  uncommon,  yet  they  are  liable  to 
be  overlooked  by  practitioners.  It  appears  that  the  rectum  becomes 
gradually  dilated  and  blocked  up  by  a  collection  of  hard  dry  fasces  which 
the  patient  has  not  the  power  to  expel.  Some  indurated  lumps  from  the 
sacs  of  the  colon,  on  reaching  the  rectum,  perhaps  coalesce  so  as  to  form 
a  large  mass;  or  a  quantity  accumulated  in  the  colon  on  descending  into 
the  lower  bowel  becomes  impacted  there.  In  several  instances  a  plum- 
stone  has  been  found  in  the  centre  of  the  mass.  Such  a  collection  gives 
rise  to  considerable  distress  and  alarm,  producing  constipation,  a  sensation 
of  weight  and  fulness  in  the  rectum,  tenesmus  and  forcing  pains,  la 
cases  of  some  duration,  when  the  hardened  faeces  do  not  quite  obstruct 
the  passage,  they  excite  irritation  and  a  mucous  discharge  which,  mixing 
with  recent  feculent  matter  passing  over  the  lump,  causes  the  case  to  be 
mistaken  for  diarrhoea.  Injections  have  no  effect  in  softening  the  indu- 
rated mass.  They  act  only  on  the  surface  and  return  immediately,  there 
being  no  room  for  their  lodgement  in  the  bowel.  On  digital  examination 
the  bowel  is  found  to  be  distended  and  blocked  up  with  a  large  lump 
which  feels  almost  as  hard  as  a  stone.  In  such  cases  the  only  mode  of 
giving  relief  is  by  surgical  interference.  The  mass  requires  to  be  broken 
up  and  scooped  out.  Sir  James  Simpson  has  described  this  affection  under 
the  head  of  "  ball-valve  obstruction  of  the  rectum  by  scybalous  masses." ' 
Some  years  ago  I  saw  a  lady  who  for  eighteen  months  had  been  unable  to 
relieve  her  bowels  without  aperients  and  without  passing  her  finger  into 
the  rectum.  On  examination  I  detected  a  hard  elongated  mass  which  was 
forced  down  in  the  effort  of  defecation  and  obstructed  the  anus  until  the 
finger  pushed  it  back.  I  broke  up  this  mass,  and  after  the  bowels  had 
been  relieved  by  injections  the  difficulty  was  entirely  removed. 

Anal  Tumors  and  Excrescences. — Besides  the  flaps  and  folds  of 
integument  consequent  on  external  piles,  other  growths  are  developed  in 
the  immediate  vicinity  of  the  anus.  These  tumors  of  a  fibrous  texture 
sometimes  form  in  the  subcutaneous  areolar  tissue,  and  as  they  increase 
become  pedunculated.  They  seldom  exceed  the  size  of  a  chestnut,  though 
1  have  known  one  to  weigh  half  a  pound.  They  have  a  firm  feel,  and 
their  surface  is  in  general  irregularly  lobulated.  These  growths  may  be 
easily  and  safely  removed  by  excision. 

Warts  are  not  unfrequently  developed  around  the  anus,  and  they 
sometimes  grow  so  abundantly  as  to  constitute  a  considerable  cauliflower- 
looking  excrescence.  They  then  form  projecting  processes  of  various 
sizes  densely  grouped  together,  many  being  of  large  size,  with  their  sum- 
mits isolated,  expanded,  and  elevated  on  narrow  peduncles  more  or  less 
flattened.  I  have  seen  a  mass  forming  a  tumor  as  large  as  the  closed  fist, 
separating  the  nates,  and  almost  blocking  up  the  passage  for  the  faeces. 
When  abundant,  they  give  rise  to  a  thin  offensive  discharge.  They  origi- 
[i.ate  in  the  irritation  consequent  on  want  of  cleanliness,  and  occur  gener- 
jally  in  young  adults  of  both  sexes.  I  once  saw  a  large  crop  of  these 
growths  in  a  child  only  four  years  of  age.  In  some  persons  there  is  so 
strong  a  disposition  to  the  formation  of  warts,  that  without  great  atten- 
tion it  is  difficult  to  prevent  their  formation.  If  few  in  number  and  small 
in  size,  they  may  be  destroyed  with  strong  nitric  acid.     They  usually  re- 

'  Edinburgh  Monthly  Jonmal  of  Medical  Science,  April,  1849. 


150         DISEASES    OF  THE   INTESTINES   AND   PERITONEUM. 

quire  however  to  be  removed  by  excision,  which  is  the  quickest  and  most 
effectual  mode  of  treatment.  Great  cleanliness  and  the  application  of 
astringent  lotions  will  be  necessary  to  prevent  their  reproduction  after- 
wards. 

Prurigo  Ani. — Itching  at  the  anus  is  a  common  symptom  in  several 
disorders  of  the  lower  bowel,  but  it  may  also  occur  as  a  distinct  affection, 
as  independently  of  any  other  disease  of  the  part,  being  due  to  a  peculiar 
hjrperaesthesia  of  the  skin.  Prurigo  ani  is  caused  by  worms  in  the  lower 
part  of  the  rectum,  and  by  congestion  of  the  haemorrhoidal  veins.  In 
women  it  is  consequent  on  affections  of  the  womb.  Patients  suffer  most 
after  taking  stimulating  drinks,  and  during  warm  weather  and  when 
heated  in  bed.  The  itching  is  extremely  teasing  and  annoying,  especially 
at  night,  when  it  sometimes  keeps  the  patient  awake  for  hours.  Rubbing 
the  part  to  arrest  the  irritation  only  aggravates  the  mischief  afterwards, 
yet  few  persons  have  sufficient  self-control  to  prevent  their  seeking  tem- 
porary relief  by  friction,  and  some,  though  capable  of  restraining  them- 
selves whilst  awake,  fret  the  part  unconsciously  during  sleep.  The  fric- 
tion thus  resorted  to  excoriates  the  skin  at  the  margin  of  the  anus,  so  that 
in  chronic  cases  the  skin  becomes  dry,  harsh,  and  leathery,  cracks  from 
slight  causes,  and  ulcers  and  fissures  are  produced,  which  are  but  little 
disposed  to  heal.  In  most  instances  this  complaint,  after  proving  trouble- 
some for  an  hour  or  two  at  night  and  in  the  day  after  stimulants,  ceases, 
and  the  patient  has  long  intervals  of  rest  and  ease.  But  in  the  worst 
forms  of  the  malady,  the  torment  is  most  distressing.  It  lasts  throughout 
the  night,  so  that  the  patients  get  little  but  broken  sleep,  and  after  a  time 
the  general  health  suffers  seriously,  and  life  is  rendered  truly  miserable. 
In  some  of  the  cases  which  have  fallen  under  my  notice,  I  could  discover 
no  local  cause  whatever  to  account  for  the  prurigo.  It  seemed  to  be 
purely  an  affection  of  the  nerves  of  the  part.  The  patients  are  generally 
healthy.  One  gentleman  who  had  been  subject  to  it  for  years,  found  that 
it  was  connected  with  his  state  of  mind.  When  much  engaged  and  pros- 
perous in  business,  he  suffered  little  from  it.  He  was  sometimes  free  for 
a  whole  month,  and  then  became  troubled  for  many  nights  in  succession. 
In  cases  of  this  kind  the  complaint,  after  proving  troublesome  for  years, 
has  been  observed  to  subside  as  age  advances. 

In  prurigo  ani  the  habits  of  living  should  be  regulated.  The  patient 
should  sleep  on  a  mattress,  and  be  as  lightly  covered  as  is  consistent  with 
comfort,  cold  bathing  or  sponging  should  be  daily  resorted  to,  and  suffi- 
cient exercise  taken  in  the  open  air.  Stimulants  and  hot  condiments  must 
be  strictly  avoided.  The  actions  of  the  bowels  are  to  be  regulated  if  ne- 
cessary by  medicine,  and  after  each  evacuation  the  parts  should  be  cleansed 
with  soap  and  water.  Every  effort  should  be  made  to  avoid  friction,  and 
the  patient  should  be  assured  that  if  he  yields  to  his  inclinations,  his  com- 
plaint will  be  rendered  worse  and  more  difficult  of  cure.  In  all  cases,  the 
condition  producing  this  troublesome  symptom  must  be  the  chief  object 
of  attention,  such  as  worms,  congestion,  &c.,  but  there  are  certain  reme- 
dies which  are  specially  adapted  to  relieve  the  irritation.  The  itching 
attendant  on  piles  may  be  arrested  by  smearing  the  anus  with  some  mer- 
curial ointment,  as  the  dilute  citrine,  or  one  containing  the  gray  oxide  of 
mercury,  or  by  lodging  in  the  parts  a  piece  of  cotton-wool  soaked  in  a 
lotion  of  oxide  of  zinc.  Lotions  of  carbonate  of  bismuth  and  glycerine, 
of  borax  and  morphia,  or  of  carbolic  acid,  are  often  efficacious  in  this  com- 
plaint. The  application  to  the  anus  of  strong  solution  of  nitrate  of  silver 
(gr.  3tx —  5  j)  ^ith  a  camel's  hair  brush  once  daily  often  gives  relief,  espe- 


DISEASES   OF   THE    RECnUM   AND    ANUS.  151 

cially  in  cases  where  the  skin  is  made  rough  and  sore  by  rubbing.  In  some 
cases  great  benefit  has  been  derived  from  chloroform  ointment.  It  pro- 
duces a  smarting  sensation  when  first  applied,  but  this  is  soon  followed 
by  ease.  In  persons  of  weak  constitution  benefit  has  resulted  from  full 
doses  of  quinine,  and  in  certain  cases  liquor  arsenicalis  with  steel  has 
helped  to  relieve  the  irritation.  I  have  sometimes  found  it  necessary  in 
severe  cases  to  order  suppositories  of  morphia  at  bed-time.  The  complaint 
is  often  very  obstina<"e,  and  much  perseverance  is  required  on  the  part  of 
the  practitioner,  and  also  of  the  patient,  to  effect  a  cure. 


INTESTINAL  WORMS. 

By   W.   H.   Ransom,  M.D.,  F.R.S. 


Inteodtjctoky  Remarks. — No  definition  of  the  disease,  such  as  stands 
at  the  head  of  each  article  in  this  volume,  is  requisite  or  appropriate  in 
treating,  from  the  point  of  view  of  the  practical  physician,  of  the  parasitic 
worms  which  inhabit  the  human  alimentary  canal.  But  it  may  be  desira- 
ble briefly  to  indicate  the  general  scope  or  plan  of  this  article,  as  well 
as  the  limits  within  which  it  will  be  restrained. 

In  most  diseases,  as  for  instance  in  the  exanthemata,  a  brief  summary 
of  the  more  constant  phenomena  may  serve  at  once  as  a  definition  and 
means  of  diagnosis;  but,  as  the  external  agents  or  exciting  causes  of 
those  phenomena  escape  our  search,  the  etiology  of  such  diseases  is  little 
more  than  an  investigation  of  the  conditions  favorable  to  their  occur- 
rence, with  speculations  upon  the  nature  of  the  exciting  cause:  while  the 
pathology  is  limited  to  a  consideration  of  the  relations  existing  among  the 
phenomena  observed  during  life  or  after  death,  and  between  these  and 
the  favoring  conditions. 

But  in  the  medical  study  of  parasites  the  whole  question  of  "the 
changes  from  a  condition  of  health  "  is  viewed  from  quite  another  stand- 
point. Here  we  can  begin  with  the  exciting  cause,  which  we  can  isolate, 
compare,  experiment  upon,  and  learn  the  natural  history  of,  before  we 
study  its  effects.  The  extension  of  knowledge  may  possibly  hereafter  en- 
able us  so  to  approach  the  study  of  cholera  or  scarlet  fever. 

In  this  article  the  order  thus  indicated  will  be  followed;  the  names  and 
zoological  position  of  the  worms  found  in  human  intestines  being  first 
stated,  the  more  important  species  will  be  described  and  their  life  histo- 
ries traced,  with  only  so  much  of  detail  as  may  be  required  for  the  pur- 
poses of  the  medical  practitioner.  Afterwards  the  changes  of  function  or 
structure  which  they  produce,  the  conditions  which  favor  their  occurrence, 
the  mutual  relations  of  the  observed  phenomena,  the  methods  of  detect- 
ing, expelling,  and  avoiding  these  pests,  will  be  treated  of. 

Those  parasitic  animals  belonging  to  the  Gregarinida  and  Infusoria,  as 
well  as  the  accidental  or  occasional  but  not  truly  parasitic  inhabitants  of 
our  intestines,  such  as  insect  larvae,  will  be  excluded  from  consideration 
here  on  account  of  their  at  present  comparative  insignificance  clinically. 
The  Trichina  spiralis  will  also  be  passed  over,  because,  although  it  attains 
its  state  of  sexual  maturity  in  human  intestines,  its  importance  to  the  phy- 
sician depends  upon  the  habit  which  its  larvae  have  of  perforating  the  tis- 
sues and  becoming  encysted  in  the  muscles.  Moreover  the  very  great 
importance  which  has  recently  attached  to  this  worm  justifies  the  devotion 
to  it  of  a  separate  article. 


154  DISEASES   OF   THE   INTESTINES   AND    PEEITONEUM. 

It  is  difficult,  if  not  impossible,  adequately  to  appreciate  the  relation 
of  intestinal  worms  to  their  bearers  without  including  in  the  investigation 
the  lower  animals.  To  do  so  here  would,  however,  be  foreign  to  the  de- 
sign of  this  work,  and  the  reader  who  seeks  for  fuller  information  on  this 
suDJect  will  do  well  to  consult  the  works  of  Ktlckenmeister,  Von  Siebold, 
Davaine,  Cobbold,  and  especially  of  Leuckart.  I  may  however  draw  at- 
tention to  two  prominent  results  of  the  comparative  study  of  Entozoa. 
They  are  so  widely  diffused  that  scarcely  any  species  of  animal  is  known 
which  is  not,  at  least  sometimes,  infested  by  them;  and  notwithstanding 
the  fact  that  they  can,  and  do,  often  injuriously  and  even  fatally  influence 
the  animals  they  infest,  yet  in  the  majority  of  cases  the  observer  is  struck 
with  the  apparently  trivial  inconveniences  they  produce. 

History. — The  intestinal  worms,  or  some  of  them,  have  been  known 
from  very  early  times.  Hippocrates  mentions  the  tape-worm,  and  Aris- 
totle described  in  addition  the  round-worm  and  the  seat-worm.  During 
the  classical  and  middle  ages  the  doctrine  of  spontaneous  generation  held 
general  sway,  and  was  thought  to  afford  a  satisfactory  explanation  of  the 
then  known  facts  as  to  the  occurrence  of  Entozoa.  Although  Swaramer- 
datn'  and  Redi*  shook  the  foundations  of  this  doctrine  in  its  application 
to  insects  and  their  larvae,  they  did  not  venture  to  apply  their  views  to  the 
Entozoa.  The  first  great  step  towards  sounder  views  was  made  by  Pallas,* 
who  taught  that  Entozoa,  like  other  animals,  sprang  from  similar  parents, 
and  were  propagated  by  means  of  eggs  which  were  transmitted  from  one 
host  to  another.  But  in  the  absence  of  direct  evidence  these  opinions 
were  for  a  time  borne  down  by  the  authority  especially  of  Rudolphi*  and 
Bremser,*  who  reverted  to  the  doctrine  of  spontaneous  generation.  Soon, 
however,  the  progress  of  biological  science,  aided  by  improved  means  of 
research,  and  directed  into  new  channels,  broke  down  this  doctrine  at  once 
and  for  all  time,  at  least  in  its  application  to  intestinal  worms;  and  the  re- 
searches of  Mehlis  (1831),*  Von  Siebold  (1835),'  and  Eschricht  (1837),* 
confirmed  the  main  proposition  of  Pallas,  and  justified  the  conclusion  of 
Eschricht,  that  Entozoa  during  their  reproduction  generally  undergo  a 
metamorphosis  and  a  migration.  Then  followed  the  brilliant  discovery  of 
alternation  of  generations  by  Steenstrup  (1842),*  the  researches  of  Von 
Siebold  (1848),"  and  Van  Beneden  (1850),"  and  the  true  life  history  of  the 
Treinatoda  and  Cestoda  was  understood.  It  remained  to  furnish  direct 
proofs  of  the  correctness  of  the  new  views,  and  these  were  given  by  Ktlck- 
enmeister (1852),"  who  fed  carnivora  on  flesh  containing  Cysticerci  and 
produced  tape-worms,  and  by  feeding  herbivora  with  ova  of  Taeniae  pro- 
duced Cysticerci.  Many  other  zealous  and  able  investigators  in  this  coun- 
try, as  well  as  in  France  and  Germany,  have  confirmed  his  results,  and 
otherwise  extended  our  knowledge  of  the  intestinal  worms.     Prominent 


'  Bibel  der  Natur.     Anfidem  Holl.  iibersetzt.     1752. 

*  Esperience  intome  agl'  InsettL     1713. 
•NeaeNord.  Beitrage.     1781, 
*Entozoor,  hist.  Natur,  vol.  I.     1808. 

*  Ueber  lebende  Wiirmer  ira  lebenden  Mensohen.     1819. 

*  Oken's  Isis.    1831. 

'  Archiv  f  Ux  Naturgeschichte.     18.35 . 
•Nova  Acta  Academ.  C.  L.,  vol.  xix.     1837. 

*  Ueber  den  G«nerationBweohsel.     1842. 

"  Jahresbericht  im  Archiv  f iir  Nattizgeschiohte.     1848. 

»'  Leu  Vers  Oestoides.     1850. 

"  Prager  Vierteljahrschrift.     1852. 


INTESTINAL   T70RMS.  155 

among  these  stand  the  names  of  Haubner,  Leuckart,'  Dujardin,*  Davaine,* 
and  Cobbold. 

The  opinions  of  medical  men  as  to  the  clinical  importance  of  intestinal 
■worms  have  varied  with  the  changes  of  biological  theory,  usually  lagging 
somewhat  behind,  but  depending  mainly  upon  it.  So  long  as  the  doctrine 
of  spontaneous  generation  in  any  of  its  forms  was  believed  to  account  for 
the  presence  of  Entozoa  a  mysterious  dread  of  their  power  for  evil  pre- 
vailed, and  evidenced  itself  by  the  multitude  of  grave  diseases  attributed 
to  them.  Indeed  few  maladies  afflict  humanity  which  were  not  sometimes 
attributed  to  intestinal  worms,  even  by  prominent  men  in  their  day. 

This  was  due  not  alone  to  the  common  tendency  to  magnify  the  un- 
known, but  also  to  the  uncertainties  of  diagnosis,  the  absence  of  a  patho- 
logical anatomy,  and  the  frequency  with  which  worms  were  observed  to 
pass  away  in  the  course  of  serious  diseases,  the  subsequent  recovery  from 
which  being  imputed  to  their  escape. 

In  the  latter  half  of  the  eighteenth  century  an  extreme  reaction  took 
place  among  those  who  gave  themselves  specially  to  the  study  of  Entozoa, 
so  that  it  was  maintained  that  they  were  beneficial  to  their  hosts,  or  at 
most  only  very  rarely  and  accidentally  injurious. 

The  physicians  as  a  rule,  however,  still  clung  to  the  older  views,  and  in 
doubtful  cases  found  a  ready  and  satisfactory  explanation  of  the  symp- 
toms in  the  assumption  of  an  irritation  by  imaginary  worms.  Even  Ru- 
dolphi  and  Bremser,  while  opposed  to  the  prevalent  medical  opinion, 
sought  to  explain  the  actual  symptoms  which  attended  the  presence  of 
worms  in  the  intestines  by  the  hypothesis  of  a  pre-existing  diathetic  state 
(Helminthiasis),  which  they  believed  to  be  a  necessary  condition  of  the 
spontaneous  development  of  worms.  Only  in  the  present  generation  have 
sound  views  on  this  subject  prevailed,  and  only  since  the  discoveries  of 
Kttckenmeister  and  his  followers  has  a  satisfactory  knowledge  of  the  life 
history  of  human  intestinal  worms  enabled  the  physician  to  appreciate 
their  true  importance  in  medicine,  to  ascertain  their  presence  with  cer- 
tainty, and  in  most  instances  to  point  out  how  they  may  be  avoided. 

Out  of  at  least  thirty-one  Entozoa  which  are  at  present  known  to  in- 
habit our  bodies,  thirteen  infest  the  alimentary  canal.  Of  these  seven 
belong  to  the  order  Cestoda  : — 


4.  Tmnia  flavo-jmnctata,  Weinland. 

5.  Tania  eUiptica,  Batsch. 

6.  Bothriocephahis  latus^  Bremser. 

7.  Bothriocq)haltLS  cordatus,  Lenckart. 


1.   Tcenia  solium,  Linnaeus. 

3.  Taenia  medio-caneUata,  Kuckenmeis- 

ter. 
3.  Tcenia  nana,Yon  Siebold. 

And  six  to  the  order  JVematoda : — 

8.  Ascaris  lumbricoides,  Linnsens.  |    11.  Doclimius  duodsnoHs,  Lenckart. 

9.  Ascaris  mt/ntax,  Rudolphi.  12.  TrichocepJmlus  dispar,  Budolphi. 
10.   Oxyuris  vermiciUaria,  Bremser,             |    13.  Trie/ana  spiralis,  Owen.* 

Order  GE8T0BA. 

Parenchymatous  worms,  without  mouth  or  alimentary  canal,  with  a 
so-called  water-vascular  system.  They  develop  by  budding  from  a  pear- 
shaped  larval  form  (scolex)  to  a  long,  jointed,  tape-shaped  colony  of  indi- 
viduals (strobila).     In  their  reproduction  they  suffer  an  alternation  of 

'  Die  raenschlichen  Parasiten,  «S5c.     1S62-68. 
'  Histoire  Naturelle  des  Helminthes.     1845. 
»  Trait6  des  Entozoaires.     1860. 
*  See  article  Triduna  spiralis. 


156 


DISEASES   OF   THE   INTESTINES   AND   PERITONEUM. 


generations.  The  individual  members  of  the  colonjr  (proglottides),  or 
sexually  ripe  animals,  increase  in  size  and  complexity  of  structure,  al- 
though otherwise  resembling  each  other,  the  further  they  are  removed 
from  the  head,  near  to  which  a  continuous  formation  of  new  joints  takes 
place  by  budding.  The  head,  which  is  the  same  in  the  adult  as  in  the 
larval  form,  is  furnished  with  two  or  four  suckers,  and  commonly  also 
with  a  coronet  of  hooklets,  which  serves  for  attachment.  They  infest  in 
their  adult  state  the  alimentary  canal  of  vertebrate  animals  only.  The 
ovum  yields  a  globular  embryo  furnished  with  three  pairs  of  hooklets,  and 
develops  into  the  Scolex  ( Cysticercus)  in  the  tissues  or  in  parenchymatous 
organs,  usually  of  food  animals,  and  is  thence  passively  transferred  with 
the  food  into  the  intestine  of  its  definitive  bearer,  where  it  assumes  the 
adult  form. 

T^NiA  SOLIUM  (LinnjBus) 

Was  at  one  time  believed  to  be  "  the  common  tape-worm  of  man,"  but  it 
is  now  known  that  at  least  one  other  species  is  included  in  that  expres- 
sion. 


Fia.  3.— Head  of  T.  soli- 
um.   (Da  value.) 


Fio.  8.— Coronet  of  hooks,  magnified, 
art.) 


(Leuck- 


Fio.  l.—Tania  »oUum 
natural  sizo.    (DaTaloe.) 


Fio.  4.— Separate  hooka,  more  highly  magnified.    (Lenckart) 


Description. — The  adult  worm  (Strobila,  Fig.  1)  commonly  attains  a 
length  of  from  7  to  10  feet,'  but  is  often  much  longer.     The  number  of 

'  This  is  Leackart's  measnrement.  but  there  is  a  wide  divergence  among  authorities 
on  this  point.     Davaino  makes  the  common  length  from  20  to  20  feet. 


INl'ESTINAL    WOUM8. 


157 


joints  increases  with  the  length;  a  worm  measuring  7  ft.  6  in.,  counted 
by  Leuckart,  had  749  joints.  The  head  (Fig.  2)  has  a  somewhat  globular 
form,  measures  about  -^^  in.  to  -^  in.,  is  marked  anteriorly  by  a  mode- 
rately prominent  rostellum,  bearing  a  crown  of  about  twenty-six  hooks, 
and  by  four  projecting  suckers. 

The  threadlike  neck  is  nearly  an  inch  in  length,  and  to  the  naked  eye 
is  not  distinctly  jointed;  it  passes  gradually  into  a  jointed, 
continually  widening  band  of  a  whitish  color,  of  which  the 
earlier  segments  are  so  much  shorter  than  broad  that  one-half 
of  the  whole  are  found  in  the  anterior  ninth  of  the  chain. 
Slowly  the  joints  increase  in  length  more  than  in  breadth,  so 
that  they  assume  a  square  form  about  the  end  of  the  anterior 
third.  Mature  joints,  Pro<jlottides  or  Cuciirhitina  (Fig.  5), 
measure  about  ^  in.  in  length  and  ^  in.  in  breadth,  being  now 
longer  than  broad.  They  are  flat  and  thin,  with  a  quadrangu- 
lar outline,  are  furnished  with  a  longitudinally  placed  tubular 
uterus,  having  seven  to  ten  branches  on  each  side,  within  which 
are  seen  developing  ova.  Male  and  female  organs  of  gener- 
ation are  present  in  the  same  joint,  and  open  by  a  common 
aperture  near  the  centre  of  one  or  other  border,  now  right,, 
now  left.  The  sexual  organs  are  already  distinctly  visible 
in  the  joints  at  one-ninth  of  the  whole  length  from  the  head, 
the  ova  are  impregnated  about  another  ninth  lower  down  the 
chain,  and  soon  afterwards  the  eggs  enter  the  uterus. 

The  water-vascular  system  consists  of  a  single  longitu- 
dinal canal  at  each  border,  and  one  transverse,  near  the  pos- 
terior edge;  it  is  continuous  from  one  segment  to  another 
throughout  the  chain.  The  cystic  worm  known  as  Cysticer- 
cus  cellulosm  is  the  larval  form,  or  Scolex  (Figs.  6,  7);  it 
is  commonly  found  in  the  flesh  of  pigs,  but  occasionally  also  in  other 
animals,  and  even  in  man:  the  adult  colony  has  only  been  found  in  man. 
The  eggs  (Fig.  8)  are  globular  in  form,  measure  when  free  about  -ij-J  j-  in.^ 


PiQ.  5.  — 
Ripe  joints  of 
T.soHMjn,  mag- 
nified. (Leuck- 
art.) 


Fia.  6.  Fia.  7.  Fia.& 

Fio.  a.—Cynticerctit  celluloice,  natural  Rize  and  position.    (Leuckart.) 
Fia.  T.—C}/sticerc7ta  ceiluloste,  magnified.     Head  and  neck  protruded.    (Leuckart.) 
FiQ.  S— Ripe  ova  of  T.  nolium.    a  with  outer  capsule  as  seen  in  uterus:  b  free,  as  found  in  faeces.. 
(Leuckart.) 

liave  a  thick  firm  shell  of  a  brownish  color,  radially  and  concentrically  stri- 
ated, and  when  taken  from  the  uterus  often  an  outer  capsule  with  a  more 
oval  outline  (Fig.  8,  a).  The  contained  embryo  is  globular,  and  furnished 
with  three  pairs  of  booklets.  A  moderate-sized  tape-worm  has  been  cal- 
culated to  contain  about  5,000,000  of  ripe  ova. 

Life  History. — The  normal  habitat  of  T.  soliiitn  is  the  small  intestine 


158  DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

of  man:  Ktlckenmeister  has  seen  it  while  yet  alive  firmly  attached  by 
suckers  and  coronets  to  the  mucous  membrane.  Formerly  it  was  be- 
lieved that  it  was  always  solitary,  and  this  error  perhaps  explains  the 
statements  made  by  the  older  authorities  of  the  occurrence  of  worms  of 
enormous  length.  It  is  now  known  that  although  commonly  one,  two,  or 
three  are  found  together,  yet  various  numbers,  up  to  forty  at  least,  may 
be  present. 

From  the  lowest  end  of  the  band — which  hangs  a  variable  distance 
down  the  intestines,  and  may  reach  the  colon — ripe  joints  spontaneously 
separate  and  escape  with  the  faeces,  either  singly  or  united  into  short 
lengths.  Frequently,  also,  ripe  ova  escape  by  rupture  from  the  joints 
into  the  intestine  and  mingle  with  its  contents.  The  free  joints  in  moist 
and  warm  situations  move  about  for  a  time,  and  by  this  and  other  acci- 
dental agencies  the  ova  are  widely  disseminated;  doubtless  the  vast  ma- 
jority fail  to  find  suitable  conditions  for  their  development,  and  therefore 
die;  but  a  small  proportion  of  joints  or  ova  are  taken  with  the  food  into 
the  stomach  of  a  pig,  or  much  more  rarely  into  that  of  a  man;  where, 
after  digestion  and  rupture  of  the  shell,  the  embryo  [pro-Scolex)  escapes, 
and  by  diligent  use  of  its  armature  perforates  the  tissues  of  its  involun- 
tary host,  and  ultimately  settles  down  in  some,  to  it,  suitable  locality, 
generally  the  cellular  tissue  of  the  muscles,  but  sometimes  the  liver  or 
the  brain.  The  embryo  there  remains  quiet,  in  some  organs  is  encysted, 
tindergoes  a  metamorphosis,  and  becomes  the  well-known  Cysticercus  eel- 
lulosce  of  measly  pork  (Figs.  6,  7).  As  usually  found,  it  has  the  head 
and  neck  inverted,  and  its  characters  are  difficult  to  observe,  but  when 
everted  is  seen  to  have  a  head  and  neck  like  that  of  T.  solium^  with  a 
vesicular  caudal  appendage.  This  metamorphosis  requires  about  two 
months  and  a  half  for  its  completion;  afterwards  the  Cysticerci  remain 
without  further  change,  but  capable  of  further  development,  if  the  proper 
conditions  are  supplied,  for  a  period  not  yet  certainly  known,  but  which 
has  been  estimated  at  from  three  to  six  years. 

When  the  flesh  of  pigs  so  infested  is  eaten  raw  or  imperfectly  cooked, 
the  Cysticercus  is  partly  digested  in  the  stomach,  so  as  to  lose  its  vesicu- 
lar annex;  it  then  passes  into  the  small  intestine,  and,  attaching  itself, 
becomes  developed  in  about  three  to  three  and  a  half  months  into  the 
adult  form  already  described,  which  may  continue  to  infest  its  bearer  for 
ten,  or  even,  it  is  said,  thirty-five  years.  It  would  take  too  much  space 
here  to  recount  the  evidence  upon  which  this  summary  statement  rests; 
but  it  may  be  said  in  brief  that  Ktlckenmeister,  Leuckart,  and  others 
have,  notwithstanding  some  opposing  statements,  placed  it  beyond  reason- 
able doubt  by  a  carefully  devised  and  executed  series  of  experiments,  in 
which  pigs  have  been  infected  with  Cysticercus  cellulosoe  by  eating  ripe 
joints  of  Tcenia  solitcnif  and  men  have  been  infected  with  tape- worm  by 
eating  measly  pork. 

This  biography  of  T.  solium  illustrates  that  of  other  parasites  of  the 
same  group,  and  the  study  of  each  has  thrown  light  upon  the  others: 
for  this  reason,  and  to  show  the  relation  between  the  food  of  animals 
and  their  parasites,  the  following  short  list  may  be  permitted  a  place 
here: — 

Cysticercus  fasciolaria  in  the  mouse  is  the  larval  form  of   Taenia 
I  erassicolles  in  the  cat. 

Cysticercus  pisiforniis  in  the  rabbit  is  the  larval  form  of  Toema  ser- 
rata  in  the  dog. 


INTESTINAL   WOBMS.  159 

Cystieercus  tenuicoUU  in  sheep,  oxen,  &c.,  is  the  larval  form  of  Toenia 
marginata  in  the  dog. 

Caenurus  cerebralis  in  sheep  is  the  larval  form  of  Tosnia  ccenunu  in 
the  dog. 

Cysticercu8  tcenicB  medio-candlatcB  in  the  ox  is  the  larval  form  of 
Taenia  medio-canellata  in  man. 

Symptoms. — There  can  be  no  question  that  a  large  proportion  of  per- 
sons infested  with  this  tape-worm  are  unconscious  of  any  departure  from 
the  state  of  perfect  health,  but  there  is  as  little  doubt  that  in  some 
instances  functional  derangements  occur  which  are  referable  to  the  local 
irritation  it  produces.  In  a  much  smaller  number  of  cases  and  under 
exceptional  conditions,  even  structural  changes  are  produced  by  it. 

The  functional  derangements  belong  to  two  groups.  («)  Those  ex- 
cited in  the  part  irritated,  and  its  immediate  neighborhood.  Such  are, 
various  uncomfortable  sensations  in  the  abdomen,  pains  resembling  colic, 
sometimes  felt  when  the  stomach  is  empty,  at  others  after  certain  articles 
of  food,  variable  appetite,  now  excessive,  now  failing  entirely,  slight 
diarrhoea,  or  constipation,  &c.  {b)  Those  of  reflex  origin.  These  are 
itching  of  the  nose  or  anus,  headache,  giddiness,  ocular  spectra,  tinnitus 
aurium,  palpitation,  cardialgia,  increased  flow  of  saliva,  nausea,  lassitude, 
pains  in  the  limbs,  and  an  uncertain  flow  of  spirits.  In  women,  disordered 
menstruation,  spasmodic  and  convulsive  movements,  hysterical  fits,  and 
even  epileptic  and  maniacal  attacks,  have  been  said  to  be  due  to  their 
irritation.  In  long-continued  cases,  Ktlckenmeister  thinks  wasting  has 
been  produced.  This  somewhat  grave  list  of  symptoms  contains  little  or 
nothing  that  is  characteristic  of  the  nature  of  the  irritative  cause,  and 
must  be  received  with  some  caution,  on  two  grounds:  one,  that  patients 
not  unfrequently  exaggerate  their  sensations  when  they  either  have  had, 
or  have  suspected  themselves  to  have  had,  worms  of  any  kind;  and  the 
other,  that  the  symptoms  enumerated  have  in  great  part  been  collected 
and  handed  down  to  us  from  earlier  times,  when  medical  men,  not  yet 
familiar  with  the  results  of  comparative  helminthology,  shared,  to  some 
extent,  the  common  mysterious  dread  of  Entozoa,  and  too  hastily  attrib- 
uted the  observed  phenomena  to  the  influence  of  worms,  which  were 
indeed  present,  but  not  necessarily  acting  as  exciting  causes.  In  support 
of  this  assertion,  it  is  suflicient  to  recall  the  fact  that  many  healthy  per- 
sons are  infested  with  tape- worms  and  present  no  symptoms;  and  also, 
that  many  persons  suffering  from  various  diseases  have  tape-worms,  and 
these  more  than  other  persons  are  apt  to  expel  them,  and  thus  mislead. 

It  may,  nevertheless,  be  readily  granted  that  those  who  have  a  deli- 
cate or  irritable  mucous  lining  to  their  intestines,  or  who  are  of  a  nervous 
temperament,  and  abnormally  liable  to  reflex  excitement,  do  suffer  some, 
perhaps  many,  of  the  symptoms  here  recounted,  and  that  in  stronger  per- 
sons the  same  may  happen  if  the  worms  are  very  numerous.  But  it  is 
worth  remembering,  that  paroxysmal  maladies,  such  as  convulsions,  mania, 
&c.,  are  peculiarly  liable  to  give  rise  to  errors  in  reasoning  as  to  their 
causes,  so  that  very  rarely  could  it  be  affirmed  that  they  were  caused  by 
a  tape-worm  when  their  cessation  coincided  in  time  with  its  expulsion. 

In  some  cases,  proportionally  few  in  number,  when  abscesses  have 
formed  in  connection  with  an  obstruction  of  the  intestine,  a  tape-worm 
has  escaped  from  the  opening,  and  may  have  been  partly,  or  perhaps 
'solely,  the  cause  of  such  obstruction  and  abscess. 

There  is  another  fortunately  rare,  but  grave,  consequence  of  the  pres^ 


160  DISEASES   OF  THE   INTESTINES   AND   PERITONEUM. 

ence  of  a  tape-worm;  it  may  give  rise  to  the  development  of  the  Cysticer* 
eits  celluloscB  in  the  tissues  or  organs  of  its  bearer,  and  thus  even  destroy 
life.  This  may  conceivably  take  place  when,  as  a  consequence  of  violent 
vomiting,  some  of  the  ripe  joints  are  carried  up  into  the  stomach,  where 
the  digestive  fluids  might  set  the  embryo  free;  or  in  the  case  of  children 
or  dirty  people,  by  conveying  the  escaped  segments  or  free  ova,  upon  the 
hands  or  with  the  food  into  the  mouth,  and  thence  into  the  stomach. 

Diagnosis. — When  a  patient  presents  such  a  conjunction  of  symptoms 
as,  in  the  absence  of  other  indications,  excites  a  suspicion  of  tape-worm, 
its  presence  can  only  be  ascertained  by  an  inspection  of  the  stools.  The 
ripe  segments  (Fig.  5)  or  the  ova  (Fig.  8,  h)  will  with  a  little  care  almost 
certainly  be  found  in  the  faeces,  and  from  them  the  species  may  be  deter- 
mined with  suflBcient  exactitude  for  the  requirements  of  the  physician. 

Etiology. — The  exciting  cause  of  the  disease  is  manifestly  the  worm, 
a  foreign  irritating  body  in  the  intestine.  The  favoring  conditions  are 
the  adult  age,  possibly  the  female  sex,  certainly  some  occupations,  such  as 
those  of  the  cook  or  the  butcher,  the  habit  of  eating  raw  or  underdone 
pork,  ham,  sausages,  &c.,  and  a  residence  in  Europe,  India,  Algeria, 
Korth  America,  and  probably  wherever  the  pig  is  domesticated. 

Pathology. — Leuckart  has  shown  by  observations  on  the  dog,  that  local 
congestions  of  the  mucous  membrane,  separation  of  the  epithelium,  and 
even  minute  superficial  sores,  may  result  directly  from  the  activity  of  a 
tape-worm.  If  it  be  admitted  that  T.  solium  may  cause  similar  local 
changes  in  man,  there  is  no  difficulty  in  connecting  the  deranged  functions 
of  the  alimentary  canal  with  the  worm  as  their  cause,  if  we  grant  either 
an  exceptional  delicacy  of  the  bearer,  or  an  unusual  number  of  worms. 
The  remote  functional  disorders  present  no  more  difficulty,  if  pre-existing 
abnormal  proclivity  to  reflex  movements  be  granted. 

Treatment. — The  indications  for  treatment  follow  in  the  clearest  man- 
ner from  the  foregoing.  The  worm  as  exciting  cause  must  be  got  rid  of, 
and  the  effects  then  commonly  subside;  but  should  they  persist  for  a  time, 
they  can  be  successfully  met  by  suitable  diet  and  the  treatment  for  irrita- 
tion of  the  intestines. 

An  immense  number  of  substances  have,  at  various  times,  enjoyed  a 
reputation  for  the  possession  of  anthelmintic  powers,  too  often  without 
any  accurate  distinction  of  the  kind  of  worm,  so  that  with  the  rise  of  a 
more  accurate  diagnosis,  as  well  as,  perhaps,  of  a  more  critical  spirit  in 
modern  times,  the  number  of  accepted  remedies  for  tape-worm  has  rather 
diminished,  and  a  general  demand  has  arisen  for  a  re-examination  of  the 
claims  of  most  of  the  reputed  agents. 

The  Maxk  Shield-feen  (Aspidium,  filix  mas)  is  perhaps  the  oldest 
and  most  widely  known  vermifuge,  and  of  late  has  grown  into  much  favor, 
especially  in  this  country. 

The  dose  is  from  60  to  100  grs.  of  the  powder  of  the  dried  rhizome,  or 
from  3  j.  to  3  ij.  of  the  liquid  extract,  given  upon  an  empty  stomach,  pre- 
ceded and  sometimes  followed  by  a  purgative.  It  has  been  said  to  act  by 
killing  the  worm;  it  certainly  has  a  violent  and  irritating  action  upon  the 
lining  membrane  of  the  stomach  or  bowels,  often  causing  vomiting,  and  in 
large  doses  purging,  with  slimy  and  even  bloody  stools. 

The  Bark  of  the  Pomegbanatb  Root  {Puniea  granatum),  also  an 
ancient  and  extensively  used  remedy,  is  recommended  by  Bamberger  as 
the  best  and  least  disagreeable  in  its  action  of  all  the  remedies  for  the  ex- 
pulsion of  tape-worm.  He  insists  upon  its  being  used  fresh,  and  consid- 
ers the  old  and  dry  bark  almost  inert.     He  prepares  the  patient  by  spare 


INTESTINAL    WORMS.  161 

diet  and  aperient  medicines,  and  then  gives  a  pint  of  a  decoction  much 
like  that  of  the  British  Pharmacopoeia  (equal  to  2  oz.  of  bark)  in  three 
doses,  at  short  intervals,  early  in  the  morning.  KUckenmeister  uses  a 
still  stronger  decoction,  and  gives  a  quantity  equal  to  4  oz.  of  the  pome- 
granate bark,  with  20  grains  of  the  ethereal  extract  of  male  fern  added. 
The  German  authorities  generally  employ  powerful,  not  to  say  violent 
measures,  for  the  expulsion  of  tape-worm,  but  how  far  this  may  be  due  to 
the  greater  resistance  which  some  species  present  is  unfortunately  not  yet 
certain. 

Kousso — ^the  flowers  and  tops  of  Srayera  antkelmintica. — In  doses  of 
J  to  ^  oz.  or  more  it  is  a  quick  and  good  anthelmintic,  much  used  in 
Abyssinia  for  the  species  of  tape-worm  there  prevalent.  It  is  not  much 
used  in  Europe,  perhaps  on  account  of  its  cost,  of  the  difficulty  of  obtain- 
ing it,  and  of  the  inconvenient  form  in  which  it  is  usually  administered. 

Kamala,  from  the  fruit  of  the  JRotlerla  tinctoria,  oil  of  turpentine, 
and  a  number  of  other  agents,  have  been  recommended,  but  it  is  not  desira- 
ble to  notice  them  here.  Some  rare  instances  occur  in  practice,  in  which 
treatment  by  any  or  all  of  the  above-mentioned  drugs  fails  to  expel  the 
worm  so  as  to  prevent  its  recurrence,  which  takes  place  probably  when- 
ever the  head  and  neck  remain  attached.  Some  cases  indeed  are  recorded 
in  which  even  the  expulsion  of  the  greater  part  of  the  band  is  not  effected ; 
and  this  not  only  when  moderate  doses  have  been  used,  but  even  after 
elaborate  preparation,  vigorous  treatment,  and  free  subsequent  purgation 
such  as  Wawruch  and  other  German  authorities  have  advised.  No  very 
satisfactory  explanation  can  be  offered  of  this  singular  power  of  resistance 
occasionally  met  with;  but  in  presence  of  the  admitted  failure  of  violent 
irritating  remedies,  it  would  seem  prudent  in  such  cases  to  continue  mod- 
erate doses  of  male  fern  or  pomegranate  for  longer  periods  of  time,  in  con- 
junction with  rigid  prophylactic  rules,  to  prevent  the  possibility  of  reinfec- 
tion. 

Prevention. — Each  person  can  secure  himself  against  Tcenia  solium 
by  eating  only  such  pork,  ham,  sausages,  &c.,  as  are  well  cooked;  but  the 
public  health  is  not  so  easily  cared  for;  it  requires  that  pigs  infested  with 
measles  should  not  be  sold  as  food,  and  doubtless  fewer  pigs  would  suffer 
from  measles  were  greater  care  taken  to  remove  or  destroy  human  excre- 
ment. 

The  Gysticercus  celliUosce  when  a  human  parasite,  is  treated  of  in  an- 
other part  of  this  work. 

T^NiA  MEDio-CANELLATA  (Ktlckenmeister). 

Description. — ^This  worm  was  formerly  held  to  be  an  unarmed  variety  of 
T.  solium,  but  Ktlckenmeister  and  Leuckart  have  recently  established  its 
specific  distinctness  both  by  observation  and  experiment.  It  has  a  gen- 
eral resemblance  to,  but  is  larger  and  firmer  in  texture  than,  T.  solium/ 
not  only  does  the  whole  band  (Strobila,  Fig.  9)  commonly  attain  a  greater 
length,  but  the  segments  are  more  numerous,  and  larger  in  all  their 
dimensions.  The  unripe  ones  are  broader  than  long,  the  ripe  ones  longer 
than  broad.  The  contained  uterus  (Fig.  10)  is  more  finely  divided  than 
in  T.  solium,,  having  from  20  to  35  branches  on  each  side.  The  common 
sexual  aperture  is  placed  alternately  on  either  border,  nearer  to  the  poste- 
rior margin  than  in  T,  solium.  The  head  is  large  (Fig.  11),  measuring 
about  ^  in.  (Davaine) ;  has  neither  rostellum  nor  coronet  of  hooks ;  is 
furnished  with  four  very  powerful  and  prominent  suckers;  and,  according 
U 


162         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 


to  Leuckart,  a  fifth  smaller  one  in  the  usual  position  of  the  rostellum  (Fig. 
15).  KOckenmeister  also  figures  a  central  canal  connected  with  the  water 
vascular  system. 


Fio.  10.— Ripe  joint 
of  T.  medio-canelUUa. 
(Leuckart.) 


Fio.  11.— Head  of  T. 
medio-canellala,  nuigni- 
fied.    (Davaine.) 


Fio.  \i.—Cy»ticeraii  T, 
medio-canellatcr,  natural  size 
and  position.    (liOuciuirt.) 


Fia.  v.— TVenia  medio-caneliata,   natural   size. 
(Davaine.) 


The  eggs  (Fig.  13)  resemble  those  of  T.  solium,  except  that  they  are 
more  oval  in  outline:  they  measure  about  -^-^  in.  by  -g-^  in. 

The  larval  form,  or  Cysticerctis  tcenicB  niedio-canellatOB 
(Figs.  13,  14,  and  15),  infests  the  flesii  and  organs  of  the 
ox,  a  fact  which  at  once  points  out  the  chief  difference  be- 
tween its  life  history  and  that  of  T.  solium.  T.  m^dio-can- 
ellata  abounds  in  Abyssinia  and  South  Africa,  and  is  also 
common  in  Europe:  it  was,  until  the  recent  researches  of 
Dr.  Cobbold,  thought  to  be  more  common  in  continental 
states  than  in  this  country;  but  it  is  now  known  to  occur 
almost,  if  not  quite,  as  frequently  amongst  us  as  71  solium 
does. 

Nothwithstanding  its  being  unarmed,  the  great  strength 
of  its  suckers  enables  the  head  to  hold  on  with  even  greater  tenacity  than 
the  T.  solium,  so  that  it  is  more  difficult  to  expel,  and  it  is  believed  to 
excite  more  marked  symptoms;  but  as  the  larval  form  does  not,  so  far  as 
is  at  present  known,  infest  man,  it  is  less  dangerous  to  life. 

The  terminal  joints  separate  spontaneously  from  the  parent  chain,  and 
often  creep  out  of  the  anus  irrespective  of  the  passage  of  faeces;  as  a  rule 
having  first  permitted  at  least  a  portion  of  their  contained  ova  to  escajje 
by  rupture  into  the  intestine. 


Fto.  14.— Cy««- 
cercun  T.  rwiio- 
canellatce.  Hend 
everted.  Mafmi- 
fled.  (Lcuukart.) 


INTESTINAL    WORMS. 


163 


So  far  as  is  at  present  known,  its  treatment  is  the  same  as  that  for  T. 
solium,  and  its  prevention  consists  in  the  avoidance  of  raw  or  underdone 
beef. 

The  three  following  Tceiiice  are  placed  by  Leuckart  in  a  separate  group, 
of  which  the  larvae  are  distinguished  by  having  comparatively  small  caudal 
vesicles,  and  are  met  with  only 
in  cold-blooded,  generally  in- 
vertebrate animals.  Those  oc- 
curring in  man  are  minute,  and 
have  been  so  rarely  met  with,  at 
least  in  Europe,  as  to  be  of  com- 
paratively little  clinical  impor- 
tance. 


T^NiA  NANA  (Von  Siebold) 

Is  scarcely  an  inch  long,  and 
about  -^  in.  wide  at  its  broadest 
part.  Head  globular,  with  an 
oval  rostellum  bearing  a  single 
row  of  22  to  24  very  minute 
hooks,  and  four  rounded  suckers. 
Eggs  globular,  ^^  in.  Found 
by  Bilharz  in  great  numbers  in 
the  duodenum  of  natives  of 
Egypt.  Its  migrations  and  me- 
tamorphoses are  unknown. 


T-^NIA  FLAVO-PTJNCTATA  (Wcin- 

land). 

Tht^    nrlnlf    ntfniriQ   n    tnni     in  ^'°-  16.— Head  of  Cv»tieercu»  T.  medio-canellata, 

ine     aauit    aiiams    a   lOOl     m      ^^^^     ^^^^^^y    magnified,     showing     central     sucker. 

length.      The  joints  of  the   an-     (Leuckart.) 
terior  half  of  the  chain  are  mark- 
ed by  a  distinct  yellow  spot,  the  receptaculum  semini,  which  is  absent  in 
the   following   segments.      Head    unknown.     The  egg  measures  ^^  in. 
Met  with  but  once  in  a  healthy  infant  in  North  America.      Life  history 
unknown. 

T-(ENIA   ELLIPTICA    (Batsch). 

The  adult  worm  attains  a  length  of  6  in.  to  8  in.,  head  very  minute, 
measuring  ^  in.,  rostellum  cylindrical,  furnished  with  three  or  four  rows 
of  booklets.  Terminal  segments  three  or  four  times  as  long  as  broad. 
Sexual  apertures  double,  one  on  each  margin  of  segment.  Eggs  measure 
■5^  in.  It  infests  normally  the  intestine  of  the  cat,  and  only 
very  exceptionally  has  been  found  in  man.  Its  life  history  is 
unknown. 

Here  I  venture  to  add  an  abstract  of  a  case  (Med.  Times 
and  Gazette,  p.  598,  1856)  which  suggests  the  possible  addi- 
tion of  still  another  species  of  Taenia  to  the  above  list.  A 
girl  aged  nine  years,  suffering  from  disordered  digestion  and 
impared  nutrition,  passed  with  the  fj^ces  for  more  than  fifteen 
months  consecutively  numerous  oval  ova  (Fig.  16),  measuring 
about  -^\^  in.  by  -^^  in.  and  containing  a  globular  embryo, 
furnished  with  three  pairs  of  booklets.  These  eggs  differed  so  much  from 
those  of  any  other  tape-worm  then  known  to  me,  that  I  referred  them  to 


Fio.  16.  — 
Ovnm  of  Tcenia 
of  uncertain 
species. 


164        DISEASES   OF   THE   INTESTINES   AND   PEKITONETJM. 

an  undescribed  species  of  Taenia;  but  whether  this  may  ultimately  prove 
to  be  correct  or  not,  the  view  receives  some  support  from  the  fact,  that 
although  the  girl  during  the  whole  of  that  time  was  under  observation 
as  a  hospital  patient,  was  treated  vigorously  and  repeatedly  with  male 
fern,  kousso,  pomegranate  bark,  turpentine,  and  various  cathartics,  and  the 
stools  carefully  watched,  yet  no  tape-worm  joints  were  ever  found,  although 
the  ova  continued  to  be  expelled  in  undiminished  numbers.  It  is  very 
difficult  to  suppose  that  the  child  harbored  a  T.  medio-canellata  which, 
although  sexually  mature,  passed  no  joints,  yet  this  is  the  only  Tmnia 
known  to  me  of  which  the  ova  have  even  a  passing  resemblance  to  those 
found  in  this  case.  It  seems  more  probable  that  the  tape-worm  was  one 
which  normally  expels  its  ova  without  casting  off  joints  of  such  dimen- 
sions, or  in  such  a  condition,  as  to  be  recognizable  in  the  stools  on  a  care- 
ful search. 

In  this  case  the  functional  disorder  subsided  shortly  after  treatment 
began,  but  as  the  ova  continued  to  escape,  it  could  not  have  been  caused 
by  the  parasite  or  parasites.  Ultimately  the  patient  ceased  to  attend, 
but  to  the  last  her  fjEces  contained  the  same  ova. 

The  two  remaining  tape-worms  of  man  belong  to  the  family  l^othrio- 
cephalidcBy  of  which  the  adult  forms  infest  chiefly  cold-blooded  vertebrate 
animals. 

BoTHEiocKPHALUS  LATUS  (Bremscr). 

Description. — This  is  the  largest  tape-worm  known  to  inhabit  man ; 
it  commonly  reaches  a  length  of  17  to  26  feet,  and  sometimes  60  feet  or 
more  (Fig.  17).  The  head  (Fig.  18)  is  unarmed,  oblong,  or  club-shaped, 
it  measures  -^  in.  in  length  by  -^  in.  in  breadth,  has  a  deeply-grooved 
longitudinal  sucker  on  each  side,  and  passes  gradually  into  a  short  thread- 
like neck.  The  joints  are  broader  than  long,  the  widest  being  \  in.  in 
length,  by  ^  in.  or  even  more,  in  breadth;  towards  the  posterior  end  of 
the  chain  they  increase  in  length  and  diminish  in  breadth,  assuming  thus 
a  more  square  form;  they  are  thicker  in  the  middle  than  at  their  margins, 
from  the  presence  there  of  the  sexual  organs,  which  form  a  rosette- 
shaped  patch  in  the  centre  of  which  the  sexual  apertures  are  placed. 
The  eggs  (Fig.  19)  are  oval,  ^^  in.  by  yf^  in.;  have  a  firm,  brownish, 
structureless  shell,  with  an  operculum  at  one  end.  While  yet  within  the 
uterus  they  present  no  trace  of  embryo  in  their  interior. 

Z/ife  History. — The  ova  escape  by  rupture  of  the  ripe  joints,  and 
probably  in  part  also  through  the  oviduct,  into  the  intestine  before  the 
joints  separate;  these  are  expelled  with  the  stools  at  rather  long  inter- 
vals; not  singly,  as  is  often  the  case  with  T.  solium  and  T.  medio-canel- 
lata, but  in  short  chains  of  2  to  4  ft.  in  length.  The  ovum  after  a  pro- 
longed sojourn  in  water  develops  a  cUiated  embryo,  which  escapes  through 
the  aperture  in  the  shell  by  forcing  open  the  lid,  and  is  furnished  with 
three  pairs  of  booklets.  On  analogical  grounds  it  is  very  probable  that 
:t  then  enters  into  the  body  of  some  aquatic  animal,  possibly  a  fish,  but 
probably  a  mollusc,  and  then  assumes  the  larval  form,  which  is  at  present 
unknown.  The  intermediate  bearer  is  probably  eaten  by  man,  and  the 
larva  assumes  the  adult  form  in  his  intestine.  J3.  latus  usually  occurs 
several  together;  it  has  a  somewhat  limited  geographical  distribution, 
not  having  been  found  beyond  the  limits  of  Europe;  in  some  countries  of 
which  only  is  it  indigenous.  It  is  common  in  the  western  cantons  of 
Switzerland,  North-western  Russia,  Sweden,  Poland,  Holland,  Belgium, 
and  Eastern  Prussia;  it  is  less  often  met  with  in  other  parts  of  Germa- 
ny, and  has  occasionally  been  imported  into  Britain.      Low-lying  damp 


INTESTINAL    WORMS. 


105 


regions  near  the  borders  of  seas  and  lakes  are  those  in  which  it  is  most 
often  abundant.  It  is  found  in  persons  of  all  ages  and  sexes,  and  in 
those  countries  where  it  is  most  frequent,  even  children  at  the  breast  are 
not  free  from  it. 

The  Symptoms  do  not  differ  from  those  caused  by  the  species  of 
ToenicB.  Its  presence  may  be  detected  by  an  examination  of  the  stools. 
It  may  be  expelled  by  the  same  drugs  as  are  employed  in  the  treatment 
of  other  tape-worms,  and  it  is  said  to  be  less  difficult  to  dislodge,  perhaps 
ozi  account  of  the  feeble  development  of  its  suckers.     No  precise  knowl- 


•■:-^ 


Fro.  18.— Head  of  Bothrio- 
cep/uUua  latus,  magnified.  (Da- 
Yaine.) 


Fio.  17.—JBothriocephalu8 
lotus,  natural  size,  (Daraine.) 


Via.  19.— Ova  of  Bothrio- 
eephaluH  latus:  a  with  contained 
yolk ;  6  empty  shell.  (Lenck- 
art.) 


edge  has  yet  been  attained  of  the  measures  to  be  taken  to  avoid  it;  but 
the  general  rule  of  carefully  cooking  all  foods  and  of  drinking  only  pure 
water  would  be  likely  to  succeed  even  in  those  countries  where  it  most 
abounds. 

BoTHRiocEPHALUS   C0RDATU8  (Leuckart). 

A  recently  discovered,  much  smaller  worm,  found  only  in  North 
Greenland  in  men  and  dogs.  It  is  known  by  its  caudate  head  and  the 
absence  of  a  neck. 

Order  KE3TAT0DA. 

Elongated,  slender,  often  thread-like  worms,  not  distinctly  jointed,  or 
provided  with  appendages;  with  a  separated  alimentary  canal,  a  terminal 


1G6         DISEASES    OF   THE   INTESTINES   AND   PERITONEUM. 

month,  an  anus  ( Gordiiis  excepted)  near  the  cau- 
dal extremity,  opening  on  the  ventral  aspect.  The 
integument  is  marked  by  two  lateral  longitudinal 
bands,  and  often  by  a  dorsal  and  a  ventral  one;  in 
the  former  are  embedded  the  nerves  with  their 
ganglia,  and  the  excretory  tubes  which  open  in  the 
surface  about  the  level  of  the  pharynx.  The  fe- 
male aperture  is  placed  near  the  central  region  of 
the  body,  that  of  the  male  near  the  anus,  and  con- 
joined with  it;  it  is  furnished  with  retractile  spicuhv, 
usually  two  or  more.  The  male  is  smaller  than  the 
female.  The  development  is  direct  and  the  meta- 
morphosis inconspicuous;  so  that  the  embryo  has 
the  general  aspect  of  a  nematode  worm.  The  order 
is  rich  in  species,  and  furnishes  as  many  parasites 
as  all  the  other  Helminthoids  put  togetner.     They 

^    infest  invertebrata  as  well   as  vertebrata,  and  no 

I    organs  escape  their  invasion. 

a 

""        AscAKis  LUMBEicoiDEs  (Linnjeus).     Common 
•I  round-worm. 

D  Description. — A  large  nematode  worm,  during 

c    life  of  a  reddish  or  brownish  tinge,  and  of  a  firm, 

I'    elastic  texture  (Fig.  20).     The  female  reaches  15 

I     in.  in  length  by  \  in.  to  \  in.  in  breadth;  and  the 

^    male  10  in.  by  ^  in.  (Leuckart).'     The  cylindrical 

s     body,  covered  by  a  cuticular  layer  and  marked  by 

^    fine  transverse  ruga?,  tapers  towards  both  ends,  but 

1    more  rapidly  towards  the  head;  in  which  is  placed 

^,    the  terminal   mouth,   surrounded  by  three  nearly 

I     equal  prominent  muscular  and  tactile  lips  (  Fig.  21), 

•S     each  nearly  as  high  as  broad,  and  marked  off  at  its 

?    base  by  a  distinct  groove.     The  inner  surface  of 

•^    each  lip  is  beset  with  about  two  hundred  very  mi- 

g    nute  microscopic  teeth.     The  triangular  mouth  con- 

^    ducts  to  a  muscular  oesophagus,  and  this  to  a  sini- 

£    pie,  almost  straight  intestine,  without  distinction 

of  stomach.     The  lateral  longitudinal  bands,  much 

more  distinct  than  the  median,  divide  the  muscular 

mass  into  nearly  equal  areas,  and  give  attachment 

to  their  fibres,  as  well  as  support  the  nerves  and 

excretory  tubes.     The  caudal  extremity,  short  and 

conical,  terminates   in  a   point,  and   in   the  male 

curves   strongly  towards   the    ventral   aspect,    on 

which  is  seen  the  cloacal  aperture  with  two  often 

projecting  spiculae  (Fig.  22).     These  are  connected 

with  a  short,  ejaculatory  duct,  which  is  continuous 

with  a  seminal  vesicle,  and  a  single  long,  tortuous, 

tubular  testis;  the    whole    male  generative   organ 

forming  a  tube  eight  times  the  length  of  the  animal. 

The  vulva  in  adult  females  opens  about  the  junction 


'  These  measarements  exceed  those  given  by  Davaine. 


INTESTINAL    WORMS. 


1G7 


of  the  anterior  and  middle  third  of  the  body,  it  conducts  to  a  short  vagina, 
this  to  a  uterus,  which  soon  divides  into  two  long  horns,  directed  back- 
wards; each  of  these  leads  to  a  short  oviduct,  which  serves  also  as  a  recep- 
taculum  seminis,  and  thence  to  a  very  long,  tortuous,  tapering  ovary.  The 
female  generative  tubes  are  eleven  times  the  length  of  the  adult  animal. 

The  ova  are  oval  in  form,  and  have  a  thick,  firm,  elastic,  brownish 
shell,  the  surface  of  which  is  generally  nodulated.  No  commencement  of 
development  is  seen  in  their  interior  when  deposited.  They  measure  ^^jf 
in.  by  j^^  in.  (Fig.  33,  a  and  b). 

lAfe  Ilistory. — So  fertile  is  the  round  worm,  that,  at  a  moderate  cal- 
culation, its  yearly  production  of  ova  may  be  taken  at  60,000,000,  so  that 
over  160,000  are  daily  discharged  into  the  intestine  of  its  bearer  by  one 
adult  female  worm.  As,  however,  several  are  often  present  together,  it 
is  easy  to  understand  that  the  stools  of  an  infested  person  are  so  thickly 
strewn  with  the  eggs  as  to  make  their  discovery  by  the  microscope  an 
easy  matter. 

Although  the  migrations  of  the  embryo  of  Ascaris  lumhricoides,  and 
the  true  history  of  its  development,  are  not  yet  ascertained  with  sufficient 
exactitude,  the  labors  of  Schubert,  Verloren,  Davaine,  Leuckart,  and 
others,  permit  the  following  history  to  be  given  as  an  approximately  cor- 
rect statement  of  the  facts.  The  ova  deposited  with  the  faeces  very  slowly 
develop  an  embryo  in  damp  earth  or  water.  The  process  may  be  complete 
in  a  month  if  artificial  warmth  be  applied,  but  in  nature  it  usually  requires 


Fio.  22. 


Fia. 


Pig.  21. — Head  of  Axcarin  lunibricoldes,  magnified.    (Davaine.) 
Fig.  22. — Caudal  extremity  of  male  A.  lumbrictmtes,  magnified.     (Lenckart.) 

Fig.  23.— Ova  of  A.  htmbrlcoidea,  from  the  stools ;  a  recently  deposited  ;  b  longer  delayed  in  the  Btoola. 
ShelU  tubcrculated. 


from  five  to  eight  months,  and  it  may  be  delayed  for  a  year  or  two  by 
cold  or  dryness.  Neither  frost  nor  complete  desiccation,  however,  kills 
the  embryo,  and  the  contained  ova  of  dried  females  develop  under  suitable 
conditions.  The  ova  do  not  normally  hatch  in  a  free  state;  Davaine  has 
preserved  them  in  water  for  five  years  without  any  visible  change  in  the 
embryo,  or  spontaneous  escape  from  the  shell.  In  this  stage  the  embryo 
has  the  general  aspect  of  a  nematode  worm,  with  an  alimentary  canal,  a 
commencing  generative  system,  and  a  terminal  boring,  embryonic  tooth. 
The  next  stage  of  their  development  is  not  known.  Davaine  maintains 
that  the  ova  with  their  contained  embryos  are  swallowed  with  impure 
water,  and  develop  directly  into  the  adult  form  if  received  into  the  intes- 
tine of  a  suitable  bearer.  But  direct  experiments  do  not  support  this 
view;  dogs,  rabbits,  oxen,  pigs,  and  men  have  been  fed  with  large  num- 
bers of  the  ova  of  A.  lumhriooicles  containing  living  embrvos  without  anv 
infection  resulting.     Similar  experiments  conducted  upon  horses,  dogs. 


168  DISEASES   OF   THE   INTESTINES    AND    PERITONEUM. 

and  cats  with  the  ova  of  their  peculiar  round- worms  have  had  similar 
negative  results,  and  it  seems  indeed  almost  certain  that  infection  does 
not  take  place  by  a  direct  transference  of  the  embryo-holding  ova  into  the 
alimentary  canal  of  the  definitive  bearer.  It  may  be  said  also  with  some 
confidence  that  the  embryos  do  not  escape  from  the  ova  to  enjoy  a  free 
existence  for  a  time.  On  analogical  and  other  grounds  it  is  a  far  more 
probable  view  that  the  ovum  is  taken  up  in  some  way  by  an  invertebrate 
intermediate  bearer,  perhaps  a  worm,  or  the  larva  of  an  insect,  and  in  it 
the  embryo  passes  through  a  necessary  portion  of  its  metamorphosis,  and 
then  enters  the  stomach  of  its  future  host  in  some  passive  mode  with  food 
or  drink. 

Ascaris  lumbricoides  infests  also  the  pig'  and  the  ox:  it  is  found  in 
man  all  over  the  known  world,  but  more  abundantly  in  some  countries  than 
in  others.  In  the  Southern  States  of  North  America,  especially  among 
the  negroes,  it  attacks  almost  every  one,  young  and  old.  In  the  West 
India  Islands,  Brazil,  Finland,  Greenland,  in  parts  of  Holland,  Germany, 
and  France,  it  is  also  very  frequently  met  with.  The  rural  population 
suffer  more  than  the  dwellers  in  towns,  and  the  inhabitants  of  low  and 
damp  localities  more  than  those  who  enjoy  higher  and  dryer  abodes.  The 
poor,  the  young — excluding  infants  at  the  breast — the  insane,  and  the 
dirty,  are  peculiarly  liable  to  be  infested.  In  certain  regions  it  has  occa- 
sionally prevailed  so  much  for  a  time  as  to  produce  a  kind  of  endemic 
malady. 

The  round-worm  normally  inhabits  the  small  intestine,  and  there  is 
some  ground  for  the  opinion  that,  unless  a  reinfection  occurs,  it  escapes 
after  some  months.  There  can,  however,  be  no  doubt  that  it  spontane- 
ously wanders  towards  the  external  apertures  under  certain  conditions 
which  are  not  well  known,  sometimes  passing  through  the  anus,  the  mouth, 
the  nose,  often  with  severe  purging,  vomiting,  or  sneezing.  After  death, 
also,  this  migration  is  not  uncommon,  and  is  probably  induced  by  a  defi- 
ciency of  food,  or  the  presence  of  some  conditions  unsuitable  for  the  wel- 
fare of  the  worm;  but  whatever  induces  it,  it  results  in  placing  the  worm 
occasionally  in  remote  and  singular  localities,  both  during  the  lifetime  and 
after  the  death  of  the  sufferer.  It  creeps  sometimes  into  the  gall  duct, 
gall  bladder,  or  hepatic  duct,  more  rarely  into  the  pancreatic  duct,  and 
may  give  rise  there  to  serious  structural  changes:  it  passes  sometimes 
through  an  ulcer  or  other  abnormal  opening  in  the  intestinal  wall,  and 
then  is  found  after  death  in  the  peritoneal  cavity,  accompanied  or  not 
with  the  signs  of  peritonitis,  according  as  it  may  have  migrated  during 
life  or  after  death;  it  escapes  sometimes  with  other  intestinal  contents 
from  abscesses  or  fistulas  in  the  abdominal  walls,  and  appears,  indeed,  in 
some  such  instances  to  have  caused  the  local  disease.  It  has  so  marked  a 
tendency  to  creep  into  small  apertures,  that  several  instances  arc  recorded 
of  its  becoming  fixed  in  the  eyes  of  buttons  and  other  similar  small  rings 
which  had  been  swallowed  by  the  patient,  and  this  habit  has  even  sug- 
gested the  swallowing  of  such  rings  to  act  as  worm  traps.  This  migratory 
instinct  has  occasionally  led  the  round- worm  along  fistulous  channels  to 
still  more  remote  cavities  or  organs;  for  example,  to  the  pleural  sac,  the 
spleen,  the  kidney,  the  bladder,  the  muscles  of  the  loin  or  neck,  the  spinal 
cord,  the  lung,  the  glottis,  the  trachea,  and  the  Eustachian  tube. 

In  the  more  favored  countries,  usually  from  one  to  five  worms  are  met 
with  together,  but  often  many  more  are  present;  cases  are  recorded  in 


'  Leuckart  considers  thia  species  identical  with  A.  SuiUa. 


INTESTINAL   WOEMS.  169 

which  various  numbers,  from  200  to  2,500,  have  been  expelled  from  one 
person  within  a  few  months,  and  1,000  were  found  present  together  in  the 
intestine  of  an  idiot  by  Cruveilhier 

Symptoms. — The  round-worm  is  one  of  the  most  frequently  met  with, 
and  is  clinically  more  important  than  any  other  human  intestinal  worm. 
When  it  is  present  in  moderate  numbers,  and  occupies  its  normal  position 
in  the  small  intestines  in  a  person  otherwise  healthy,  there  are  often  no 
discoverable  disorders  of  structure  or  function.  When  present  in  greater 
numbers  or  infesting  a  delicate  person,  it  is  accompanied  by  the  symptoms 
of  irritation  of  the  lining  membrane  of  the  alimentary  canal,  and  by  con- 
sequent impaired  nutrition  and  reflex  phenomena.  Thus  it  may  be  at- 
tended with  pain  in  the  abdomen,  especially  in  the  umbilical  region,  nau- 
sea, impaired  or  variable  appetite,  mucous  stools,  and  tumid  abdomen. 
Sometimes,  also,  pallor  of  the  surface,  dilated  pupils,  swollen  eyelids, 
squinting,  irritation  of  the  nostrils,  grinding  of  the  teeth  during  sleep, 
&c. :  indeed,  all  the  allied  symptoms  which  have  been  attributed  to  tape- 
worm. But  these  are  by  no  means  constant  effects  of  the  presence  of 
round-worms  in  the  intestine,  nor  are  they  peculiar  to  their  irritation. 
They  may  be  absent  when  worms  are  present  in  considerable  numbers; 
and  may  be  present  when  no  worms  infest  the  patient;  or  present  with  the 
worms  but  not  caused  by  them.  They  have,  therefore,  little  or  no  diag- 
nostic value.  Sometimes,  however,  especially  when  the  intestine  contained 
these  worms  in  very  large  numbers,  they  have  caused  grave  local  irritation 
as  well  as  constitutional  disturbance,  and  then  post-mortem  examinatioa 
has  shown  evidences  of  local  superficial  congestions  and  inflammation  so. 
closely  related  to  them  in  extent  or  position,  as  to  leave  no  doubt  of  their 
causal  relation.  Thus  cases  are  recorded  where  numerous  round-worms>. 
cohering  to  each  other,  gave  rise  to  fatal  obstruction  and  inflammation  of 
the  intestines,  and  others  in  which  they  have  excited  serious  and  even 
fatal  convulsions  in  susceptible  persons.  Although  in  these  latter  eases 
the  reflex  symptoms  are  probably  in  no  essential  point  different  from 
those  caused  by  other  irritations,  it  is  important  to  trace  them  to  the- 
worms,  if  it  can  be  done,  because  of  the  comparative  facility  with  which 
the  exciting  cause  can  be  removed.  In  the  rarer  cases  in  which  the  round- 
worm wanders  during  life  into  distant  cavities,  organs,  or  passages,  the 
disorders  they  induce  vary  with  the  parts  visited,  and  may  be  of  great 
severity,  or  even  terminate  fatally. 

Diagnosis. — When,  for  any  reason,  a  patient  is  suspected  to  harbor 
round-worms,  it  has  been  a  not  unfrequent  practice  to  employ  the  usual 
treatment  for  their  expulsion — often  a  rather  vigorous  one — as  a  means  of 
diagnosis;  and  should  no  worms  be  passed,  it  has  been  assumed  that  none 
were  present:  thus  submitting  the  patient  to  treatment  before  the  need 
for  it  is  made  out,  and  assuming,  somewhat  hastily,  that  the  recognized' 
treatment  may  be  relied  upon. 

An  easy  and  satisfactory  method  of  diagnosis  consists  in  the  micro- 
scopic examination  of  the  stools,  in  which,  if  the  suspected  person  har- 
bors a  mature  female,  the  ova '  are  readily  seen.  I  published  a  case  in 
the  Medical  Times  and  Gazette  for  June  14th,  1856,  which  so  well  illus- 
trates the  value  of  this  method  for  diagnosis,  and  its  bearing  on  treat- 
ment, that  I  venture  to  give  here  the  following  summary  of  it: — 

'  It  is  curious  to  note  that  these  ova  have  been  described  as  cholera  corpuscles 
{Lancet,  1849,  p.  532)  ;  and  more  recently  as  "choleraphyton,"  in  the  DeutsdiA 
Klinik,  1867. 


170         DISEASES   OF   THE   INTESTINES   AND   PERITONEUM. 

A  girl,  aged  twelve  years,  had  passed  two  round-worms  before  she 
came  under  observation,  and  had  complained  for  six  weeks  of  abdominal 
pains  and  disordered  digestion.  For  convenience  of  observation  she  was 
admitted  into  hospital  Feb.  14th,  1855;  her  stools  then  contained  ova  of 
Ascaris  lumbHcoides  (Fig.  23).  After  nine  days,  during  which  she  was 
treated  by  a  mixture  of  bicarbonate  of  soda  and  infusion  of  quassia,  with 
rest  and  good  diet,  she  declared  herself  well,  but  had  passed  no  worms.  For 
ten  days  more  she  was  treated  by  oil  of  male  fern  and  castor  oil,  followed 
by  scammony,  without  effect.  For  a  further  period  of  ten  days  she  took 
infusions  of  quassia  and  senna,  also  without  result.  For  five  weeks  more 
she  was  given  turpentine  and  castor  oil,  or  turpentine  alone,  at  weekly 
intervals;  and  about  the  third  or  fourth  day  after  each  dose,  except  the 
last,  she  passed  one  or  two  worms,  generally,  but  not  always,  motionless. 
The  ova  were  still  abundant  in  the  stools,  but  the  treatment  failing  to 
expel  any  more  worms,  she  was  given  Dolichos  pruriens  for  four  days, 
until  it  caused  nausea,  when  it  was  omitted;  but  for  twelve  days  more  she 
expelled  occasionally  one  or  two  worms  with  the  stools.  The  Dolichos 
pruriens  was  then  repeated  for  eight  days,  and  again  omitted;  after 
which  she  passed,  in  the  following  fortnight,  three  more  worms.  The  ova 
were  then  found  to  be  absent  from  the  stools,  and  she  was  discharged. 
While  under  treatment  she  passed  in  all,  seventeen  round- worms;  but 
during  the  last  three  months  and  a  half  she  was  in  perfect  health,  and 
would  have  been  discharged  but  for  the  observation  of  the  ova  in  the  faeces. 

Davaine  drew  attention  to  the  value  of  this  method  of  diagnosis  in 
1857  ( Comptes  Hendus  iSoc.  Biologic^  2*  Sorie,  t.  iv.  p.  188) ;  and  Leuck- 
art  says  (Die  menschliehen  Parisiten,  &c.,  B.  ii.  p.  251,  1867),  "  In  the 
microscopic  examination  of  the  faeces  we  possess  a  means  to  determine 
the  presence  of  the  round- worm,  which  is  as  easy  as  it  is  sure;  if  it  were 
more  generally  practised,  many  errors  of  diagnosis,  and  many  useless,  if 
not  injurious  treatments,  would  be  avoided." 

The  Etiology  and  Pathology  of  the  disorders  induced  by  round- worm 
have  appeared  on  the  surface  during  the  previous  observations. 

Treatment. — The  indications  are  to  relieve  the  irritation  of  the  alimen- 
tary canal  and  improve  the  general  nutrition  where  that  has  suffered,  but 
above  all  things  to  expel  the  worms.  Many  of  the  substances  which  have 
obtained  a  reputation  as  anthelmintics  have  been  much  used  for  round- 
worm, but  we  have  as  yet  no  sufficiently  exact  knowledge  of  their  action 
upon  the  different  species  of  intestinal  worms  to  enable  us  to  estimate 
their  true  clinical  value  in  the  treatment  of  Ascaris  Imnbricoides.  There 
exists,  however,  a  very  general  concurrence  of  opinion,  which  I  believe  to 
be  well  founded,  in  favor  of  the  use  of  santonica  or  worm-seed,  the  unex- 
panded  flower-head  of  an  undetermined  species  of  Artemisia,  as  well  as 
of  its  active  principle,  santonin.  The  dose  of  worm-seed  is  from  60  to  120 
grains,  but  it  is  not  much  used  on  account  of  its  inconvenient  form;  that 
of  santonin  which  is  more  used,  is  from  one  to  three  grains  twice  daily  to 
a  child,  and  from  three  to  six  grains  for  an  adult.  After  a  short  course 
of  this  medicine,  an  aperient  may  be  given  with  advantage.  It  is  apt 
to  produce  a  singular  although  but  temporary  perversion  of  vision  if 
given  in  too  large  doses,  or  for  too  long  a  time,  objects  seeming  to  be 
yellow,  blue,  or  green.  The  urine  also  may  be  tinged  red  after  its  use. 
Violent  cathartics  do  not  deserve  much  confidence,  nor  are  the  drugs 
emploved  for  tape-worm  (except,  perhaps,  turpentine)  to  be  trusted  to. 
Dolichos  pruriens  would  seem  to  be  worthy  of  further  trial  in  some  cases 
where  santonin  is  not  available,  but  of  the  numerous  other  substances 


INTESTINAL    WORMS. 


171 


which  have  been  at  times  recommended  for  the  treatment  of  A.  litm- 
Irricoides,  it  is  unnecessary  to  say  more  here. 

The  Prevention  of  Ascaris  lunibricoides  cannot  be  so  confidently 
treated  of  as  was  that  of  T.  solium,  because  we  are  not  certain  how  it 
enters  our  bodies;  but  whether  we  hold  with  Leuckart  that  an  interme- 
diate bearer  is  essential,  or  with  Davaine  that  it  is  not,  and  that  wo 
drink  the  ova  in  impure  water,  in  all  probability  the  careful  cooking  of  all 
our  foods  and  drinks  would  prove  a  good  protection  even  in  those  coun- 
tries and  districts  in  which  this  pest  most  abounds.  It  is  not,  however, 
probable  that  well-filtered  water  could  convey  the  infection. 

AscARis  MYSPAX  (Zeder) 

Is  the  common  round-worm  of  the  cat,  and  is  identical  with  Ascaris  inar- 
yinata  of  the  dog  (Schneider). 

Description. — It  is  smaller  and  more  slender  than  A.  Inmbricoides,  has 
two  small  lateral,  cuticular,  wing-like  appendages  near  the  head.  The  vulva 
in  the  adult  female  occurs  about  one-fourth  of  the  whole  length  from  the 
head.  In  man  it  has  only  been  found  parasitic  in  three  trustworthy  in- 
stances, which  are  recorded  by  Bellingham,  Cobbold,  and  Leuckart. 

OxTUBis  VERMicuLARis  (Bremser),  (Common  seat-worm). 

Description. — A  small  whitish  fusiform  worm,  the  female  attaining 
■^  in.  in  length  by  -^j^  in.  in  thickness,  and  the  male  about  ^  in.  in  length 
by  j^f^  in.  in  thickness  (Fig.  24). 
The  head  (Fig.  34  b,  d)  is  furnished 
with  three  inconspicuous  lips  around 
a  terminal  mouth,  and  an  elongated 
vesicular  expansion  of  the  cuticular 
layer  on  its  dorsal  and  ventral  aspects. 
The  oesophagus  is  continuous,  with  a 
muscular  stomach  containing  three 
teeth,  and  then  follows  a  simple  intes- 
tine. The  surface  is  marked  by  fine 
transverse  rugas,  and  the  lateral  longi- 
tudinal bands  form  a  slight  angular 
projection.  The  female  has  a  long, 
awl-shaped,  caudal  extremity  (Fig. 
24  c);  the  vulva  is  situated  about  the 
junction  of  the  anterior  and  middle 
thirds  of  the  body,  and  conducts  to  a 
vagina,  a  bifid  uterus,  and  this  to  two 
tubular  ovaries.  The  male  has  a 
blunted  tail  end  furnished  with  six 
pairs  of  papillae,  and  a  single  spiculum 
communicating  with  the  anal  aperture. 
The  eggs  (Fig.  25)  are  oval  but  flat- 
tened on  one  surface,  measure  yVoTT  ^"• 
by  ^-jj.  in.,  contain  at  the  time  of  deposition  a  developing  embryo,  and  have 
a  firm  shell  consisting  of  three  layers,  one  of  which  is  absent  at  one  pole, 
so  as  to  facilitate  the  escape  of  the  embryo.  A  moderate  estimate  allows 
10,000  to  12,000  ripe  ova  for  the  uterus  of  a  single  female. 

Xi/'e  History. — The  seat-worm,  like  the  round-worm,  is  found  all  over 
the  world,  and  is  perhaps  even  more  frequently  met  Avith.  It  is  said  to 
abound  particularly  in  Egypt  and  in  Greenland.     It  normally  inhabits  the 


Pio.  24. — Oxt/uris  Vermicularis.  a  Natnrol 
size,  b  Head,  magnified,  c  Tail,  magnified,  d 
Head,  more  magnified.     (Daraine.) 


172         DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

colon  of  man  only,  especially  in  the  neighborhood  of  the  rectum,  and  is 
commonly  found  in  large  numbers,  the  males  fewer  than  the  females,  and 
it  often  migrates  spontaneously  through  the  anus.  The  ova  are  dis- 
charged into  the  intestine  of  the  infested  person,  and  there  undergo  a 
further  development,  so  that  at  the  period  of  their  escape  with  the  stools 
they  usually  contain  a  distinctly  formed  embryo.  The  frequent  sponta- 
neous migrations  of  the  ripe  female  also  often  lead  to  the  deposition  of 
the  ova  upon  the  skin  and  hair  in  the  neighborhood  of  the  anus. 

The  ova  deposited  with  the  stools  rather  rapidly  develop  under  favor- 
able conditions,  especially  moisture  and  the  warmth  of  the  sun;  they  are 
not  killed  by  extreme  cold  or  by  desiccation,  but  a  few  days'  delay  in 
water  kills  them  outright,  and  under  ordinary  circumstances  they  die  in  a 
few  weeks  unless  their  progress  has  been  arrested  by  cold  or  dryness.  It 
does  not  seem  that  they  hatch  in  the  free  state. 

Kilckenmeister  and  Vix  conceive  that  all  the  transformations  from 

the   embryo   to  the  adult  form  take   place  within  the  intestine  of  the 

infested  person  without  any  necessary  migration,  and  at 

first  sight  this  view  seems  to  receive  support  from  the 

fact  that  large  numbers   of   seat-worms  are   commonly 

found  together,  and  that  various  grades  of  development 

Tin.  25.   Ovum  of     *'*®  there  met  with.     This  view,  however,  is  out  of  ac- 

oxyuria  vermicuia-     cord  with  the  general  law  of  development  in  parasitic 

rw,  from  the  faeces.  •        ■,  •,    ■,    ^  .         «>        .  i-^i        i  i?^ 

(Leucitart.)  anmials,  and  does  not  sufhce  to  explain  the  known  tacts. 

Leuckart  insists  that  the  emigration  of  the  embryo  is  a 
necessary  condition  of  its  future  development,  and  has  indeed  almost 
proved  the  correctness  of  this  view  by  observation  and  experiment,  as  well 
as  by  powerful  arguments.  His  view  is,  that  ova  deposited  with  the 
fjeces  are  abundantly  and  widely  scattered  in  the  dry  state  by  winds  and 
other  agencies,  and  then  are  taken  into  our  stomachs  upon  uncooked  fruits 
and  vegetables  and  in  various  other  conceivable  modes;  there  exposed  to 
the  digestive  fluids,  the  embryos  escape,  are  carried  down  into  the  colon 
and  attain  the  adult  form  probably  in  about  two  weeks.  A  sort  of  self 
infection  frequently  may  take  place  also;  in  persons  already  infested,  it 
is  easy  to  see  how  the  ova  upon  the  skin  and  hairs  near  the  anus  may  be 
conveyed  to  the  mouth  by  the  fingers,  after  scratching  to  allay  the  vio- 
lent irritation  which  these  small  pests  produce;  and  in  otiier  modes  the 
eggs  may  find  their  way  into  the  stomach  from  the  soiled  bed  clothes  or 
personal  linen.  These  views  explain  some  long-known  facts  which  are 
not  otherwise  so  easily  understoood;  for  instance,  the  great  length  of 
time  during  which  some  persons  suffer  from  seat^worms,  and  the  liability 
to  relapses  notwithstanding  repeated  treatment;  the  frequency  with 
which  these  worms  are  found  inhabiting  many  members  of  one  family  or 
household,  the  greater  liability  of  children,  of  dirty  or  insane  people,  and 
of  persons  who  often  eat  uncooked  fruit  and  vegetables,  as  well  as  the 
immunity  of  infants  at  the  breast. 

SyTn2itoms. — When  only  a  few  seat-worms  are  present  they  give  rise 
to  no  inconvenience,  and  are  usually  only  accidentally  discovered  in  the 
stools.  When  they  are  more  numerous  or  the  patient  is  more  sensitive, 
tliey  cause  an  itching  or  tickling  in  the  anus  and  its  neighborhood,  which 
is  sometimes  intolerable  to  the  sufferer,  ^specially  at  a  certain  hour  in  the 
evening.  In  the  female  it  is  peculiarly  distressing,  from  the  habit  which 
the  worm  has  of  wandering  into  the  vagina;  but  in  both  sexes  inordinate 
sexual  excitement  sometimes  is  produced.  Although  there  is  sometimes 
evidence  of  local  irritation  in  the  shape  of  excess  of  mucus  in  the  fjeces 


INTESTINAL    WORMS. 


173 


and  punctiform  redness  around  the  anus,  the  cases  of  severe  convulsion 
and  other  nervous  disorders  which  have  been  re- 
ferred to  the  action  of  seat-worms  must  be  received 
with  much  caution. 

Diagnosis. — Inspection  of  the  stools  will  dis- 
cover the  worms;  and  a  microscopic  examination 
will  show  the  ova. 

IVeatment. — Probably  any  infected  person  who 
adopted  the  requisite  precautions  against  reinfec- 
tion from  himself  or  others  would  get  well  in  a  few 
weeks  without  treatment  by  drugs,'  but  this  period 
would  be  shortened  by  the  use  of  aperients,  and 
occasionally  injections  into  the  rectum  of  cold 
water,  turpentine  and  castor-oil  with  gruel,  and  of 
preparations  of  wormwood,  quassia,  assafoetida, 
santonin,  &c.  Frequent  external  applications  of 
mercurial  or  other  ointments  and  lotions  likely  to 
kill  the  embryos  might  be  employed  also. 

Prevention. — From  the  foregoing  history  it  may 
be  learned  that  a  sufferer  from  seat-worms  should 
avoid  touching  the  neighborhood  of  the  anus, 
should  be  scrupulously  clean  *  in  person  and  cloth- 
ing; that  persons  not  yet  infested  should  avoid 
close  personal  contact,  especially  in  bed,  with  those 
who  harbor  the  worms,  and  should  always  adopt  the 
caution  of  eating  only  well-cooked  food. 


Family  STRONGYLIDES. 


Fia.  26. — Male  and  femnle 
Pochniiuti  (tuodettalit,  maKni- 
fled.     (Leuckart.) 


DocHMius  DUODENALis  (Lcuckart). 
This  minute   but    dangerous   parasite  was   dis- 
covered by  Dujardin  in  1838  in  Northern  Italy;  its 

zoological  position    is  scarcely  yet  settled,  but  its    close  affinity  to  the 
genus  Dochmius  of  Dujardin  has  been  shown  by  ilolin  and  Leuckart. 

Descriptio)i. — It  is  a  small  somewhat  cylindrical 
worm:  the  females  measure  -^  in.  and  the  males  *^ 
in.  in  length  (Fig.  20).  The  terminal  mouth  is  sur- 
rounded by  a  dilated  capsule  directed  obliquely  back- 
wards and  furnished  with  four  large  teeth  on  its  longer 
or  ventral  border,  and  with  four  smaller  ones  on  the 
opposite  or  dorsal  margin  (Fig.  27).  The  bursa  of  the 
male  is  complex,  the  spicula  two  in  number.  The  vul- 
va of  the  female  is  placed  a  little  behind  the  centre. 
The  eggs  are  oval,  measure  -j-J-^-  in.  by  y^jVc"  i"-?  8^"^ 
when  deposited  contain  a  yelk  in  process  of  cleavage. 
We  know  as  yet  but  a  part  of  its  life  history  by 
direct  observation,  and  infer  the  remainder  from  that 
of  the  better  known  and  very  closely  allied  J).  tri(/o- 
nocephalu^  of  the  dog.  The  ^^p;,  after  escaping  with 
the  stools,  under  favorable  conditions  hatches  in  a  few 
days,  and  the  embryo  enjoys  a    free    existence  for  a  time  in   mud  and 

'  This  appears  to  be  a  daring  Btatement  in  the  face  of  past  experience,  but  its  prob- 
ability is  measured  by  the  evidence  of  the  life  history  here  given. 

■*  The  common  Hindoo  custom  of  washing  after  every  act  of  defalcation  la  worthy 
of  more  frequent  imitation  in  this  country. 


Fio.    27.  —  Head    ol 

Dochmiu.%  duo<tenali\ 
magnified,  showing  the 
armature  of  the  mouth 
capsule.     (Leuckart.) 


174 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM. 


muddy  water.  It  is  taken  into  our  stomach  by  drinking  impure  water 
without  the  intervention  of  any  intermediate  bearer,  and  there  it  grows 
and  develops  to  some  extent  before  it  passes  on  into  the  duodenum  or 
jejunum,  where  the  adult  form  is  assumed.  It  then  attaches  itself  by 
its  powerfully  armed  mouth  to  the  villi  of  the  mucous  membrane,  and 
sucks  the  blood  of  its  host.  Sometimes,  under  conditions  not  yet  ex- 
plained, it  becomes  encysted  between  the  mucous  and  muscular  coats  of 
the  gut.  It  occurs  in  warm  countries  only,  has  been  found  in  Italy  (Du- 
bini),  Brazil  (Wucherer),  and  in  Egypt  (Pruner,  Bilharz,  Griesmger), 
where  it  is  a  very  frequent  and  dangerous  pest,  infesting  about  one- 
fourth  of  the  entire  population.  It  is  present  in  large  numbers  together, 
often  by  hundreds,  sometimes  by  thousands,  and  then  may  cause  frequent 
and  dangerous  haemorrhages  into  the  bowels,  followed  by  an  anjjcmic  condi- 
tion,  which  is  often  fatal,  and  to  which  the  name  of  Egyptian  chlorosis 
had  been  given  before  Griesinger  pointed  out  its  true  nature. 

Doubtless  its  ova  might  be  found  in  the  stools  of  infested  persons,  but 
of  the  treatment  which  should  follow  a  diagnosis  so  established  little  can 
be  said,  except  that  Griesinger  recommends  turpentine,  and  that  santonin 
and  such  other  substances  as  are  believed  to  expel  nemetode  worms  should 
be  tried.  Care  should  also  be  taken  to  consume  only  pure  water  or 
drinks  which  have  been  boiled,  so  as  to  avoid  reinfection,  and  the  patient 
might  then  be  fairly  expected  to  outlive  the  worm. 

Although  to  the  practitioner  in  Britain  this  parasite  is  not  of  practi- 
cal import,  it  seems  so  probable  that  it  may  be  found  in  India  or  some  of 
the  tropical  British  colonies,  that  I  have  ventured  to  include  it  here. 

Family  TRICHOTRACHELIDES. 
Teichocephalus  dispae  (Rudolphi). 

Description. — The  female  measures  about  \^  in.  the  male  about  \^  in. 
in  length.  The  anterior  three-fifths  of  the  body  are  threadlike,  measur- 
ing Y3*if^  in.  only  in  thickness,  and  bear 
a  simple  terminal  mouth  without  pap- 
illae. The  posterior  two-fifths,  about  -^ 
in.  in  thickness,  contain  the  generative 
organs  and  the  intestinal  canal;  in  the 
male,  it  is  spirally  coiled,  in  the  female 
slightly  curved  (Fig.  28).  The  caudal 
extremity  is  rounded  off  in  the  male,  and 
bears  a  single  blunt  spiculum  in  a  tubular 
protrusile  sheath  which  is  furnished  with 
teeth.  The  vulva  in  the  female  opens 
about  the  level  of  the  stomach  into  a 
vagina,  the  walls  of  which  are  furnished 
with  teeth,  and  often  prolapse.  The  large 
uterus  contains  thousands  of  eggs,  which 
are  elliptical  in  form,  and  have  a  nipple- 
shaped  projection  at  each  end.  They 
measure  ^5^  in.  by  ^^  in.  (Fig.  29), 
and  have  a  firm  brownish  yellow  shell, 
wanting  at  each  pole,  so  as  to  leave  an 
aperture  which  is  closed  by  a  firm  trans- 
parent nipple-shaped  plug.  As  found  in  the  stools  the  yelk  shows  no 
trace  of  commencing  development. 


Fio.  28.— Male  and  female  Trichocephatua 
Oitpar,  magnified.    (Leuckart.) 


INTESTINAL    WOKMS.  175 

Life  History. — The  Trichocephahis  crenahcs  of  the  pig,  and  also  tlmt 
found  in  some  monkeys,  is  probably  the  same  as  our  T.  dispar.  It  is  met 
with  in  most,  if  not  in  all,  European  countries;  in  Syria,  Egypt,  and 
North  America;  it  abounds  in  Italy,  and 
in  some  Eastern  lands;  but  is  said  to  be 
comparatively  rare  in  Copenhagen  and  in 
London  (Cobbold).  It  does  not  gener- 
ally occur  in  large  numbers  together, 
although  sometimes  hundreds  have  been 
found.  The  head  of  the  colon  is  its 
chosen   residence,  but  occasionally  it  is  piQ.  29.— Omin  of  r.  diapar. 

met  with  in  the  intestines  near.     During 

the  life  of  its  host,  it  attaches  itself  by  thrusting  its  long  whip-like  neck 
into  the  mucous  membrane.  The  ova  deposited  with  the  stools,  like  those 
of  Ascaris  lunibricoides,  very  slowly  develop  normally  in  damp  earth  or 
water,  so  that  in  warm  weather  and  under  favorable  conditions  the  embryo 
is  formed  in  about  four  or  five  months;  but  in  cold  weather  or  exposed  to 
temporary  drought  it  requires  a  year  and  a  half  or  more.  In  this  state 
the  embryo  remains,  and  neither  develops  further  nor  leaves  the  shell  to 
become  free.  (Davaine  has  preserved  them  alive  in  this  state  for  four 
years.)  From  Leuckart's  experiments  upon  the  Trichocephali  of  sheep 
and  pigs,  it  is  highly  probable  that  no  intermediate  bearer  intervenes,  but 
that  we  swallow  the  ova  with  their  contained  embryos  in  some  accidental 
manner,  as  dust  upon  uncooked  fruit,  vegetables,  &c.  &c.,  and  that  the 
embryos  escape  into  our  stomachs  after  partial  digestion  of  the  shells, 
develop  somewhat,  and  then  travel  onwards  to  the  colon,  where  they  be- 
come sexually  mature  in  four  or  five  weeks. 

No  symptoms  are  known  to  be  caused  by  T.  dispar,  although  some 
writers  have  attributed  severe  reflex  disorders  to  them  when  present  in 
large  numbers.'  The  worm  may  be  readily  shown  to  be  present  by  find- 
ing the  ova  in  the  stools.  A  satisfactory  treatment  by  drugs  is  not  yet 
known,  but  there  is  consolation  in  the  reflection  that  the  parasite  has 
probably  a  short  duration  of  life,  and  that  we  may  prevent  further  infec- 
tion by  avoiding  uncooked  foods  and  drinking  pure  water. 

'  When  Roderer  and  Wagler,  about  a  century  ago  rediscovered  this  worm,  Morgag- 
ni's  prior  observation  having  been  forgotten,  they  supposed  that  it  produced  the  typhoid 
fever  then  prevailing  at  Gottingen.  It  is  not  difficult  to  see  how  such  an  error  arose, 
the  worms  having  been  found  in  the  bodies  of  most  of  the  victims  of  the  fever,  and 
nearly  coinciding  in  seat  with  the  local  manifestations  of  the  disease.  In  connection 
with  this,  it  is  noteworthy  that  the  more  modem  theory  of  the  etiology  of  typhoid  fever 
receives  an  indirect  support  from  the  fact  that  every  person  who  is  shown  to  be  in- 
fested with  those  very  common  Entozoa  Ozyuria  vermicularis  or  TrichocepJuUuH  dispar 
is  thereby  demonstrated  to  have  swallowed  minute  portions  of  his  own  or  another  per- 
son's faeces. 


PERITONITIS. 

By  John  Richabd  Wardell,  M.D,,  F.R.C.P. 


Dtfinitiow. — An  inflammation  of  the  serous  membrane  which  invests 
the  abdominal  organs  and  lines  the  abdominal  cavity.  It  may  be  partial 
or  limited,  or  it  may  be  diffused  over  the  entire  inner  surface  of  the  peri- 
toneal sac.  Effusion  is  almost  the  invariable  consequence,  and  examina- 
tion after  death  discovers  serum,  albuminous  exudation,  sero-purulent,  pur- 
ulent, or  sero-sanguineous  fluid  and  organized  adhesions. 

Preliminary  Ohservations. — Inflammation  of  the  peritoneum  is 
characterized  by  the  kind  of  phenomena  which  are  exemplified  in  the  in- 
flammation of  the  other  serous  membranes.  It  may  occur  at  all  ages,  in 
every  description  of  temperament,  and  under  the  most  varied  conditions 
of  the  system.  It  attacks  the  earliest  infancy  as  well  as  the  adult  and 
those  in  advanced  life,  and  both  sexes  are  equally  liable  to  the  aft'ection. 
It  happens  to  the  robust  and  plethoric,  the  cachectic  and  attenuated,  and 
also  to  those  whose  constitution  has  been  undermined  and  broken  down; 
and  whenever  its  distinguishing  symptoms  are  really  proclaimed  it  is  one 
of  the  most  formidable  maladies  with  which  the  physician  has  to  deal.  It 
may  come  on  suddenly  with  apparent  and  easily  recognized  symptoms,  or 
it  may  supervene  slowly  and  insidiously,  and  continue  for  a  time  without 
being  detected.  It  may  be  primary  when  it  is  difficult  or  absolutely  inca- 
pable of  connection  with  any  foregoing  or  coetaneous  disease.  It  may  be 
consecutive  upon,  or  symptomatic  of,  some  other  morbid  condition.  It 
may  present  the  sthenic  or  asthenic  form.  And  it  may  be  met  with  only 
in  sporadic  cases,  or  prevail  as  an  epidemic.  Every  example  of  the  com- 
plaint will,  if  carefully  studied,  exhibit  some  peculiarity — some  cognizable 
difference  in  its  physiognomy,  if  such  term  may  be  employed — dependent 
upon  the  degree  of  mal-nutrition,  or  the  metamorphosis  of  the  tissues, 
upon  the  operation  of  external  agencies,  the  time  of  life,  the  amount  of 
vital  power,  and  the  idiosyncrasies  of  the  patient.  It  will  be  modified  by 
the  state  of  the  depurative  organs,  and  especially  by  that  of  the  kidneys, 
because  those  deleterious  and  effete  matters  which  ought  to  be  carried  off 
by  the  renal  organs,  when  retained  in  the  circulation,  are  particularly 
prone  to  institute  the  inflammatory  process  in  serous  membranes.  When 
the  disease  is  regarded  in  all  its  phases  and  its  cardinal  signs  are  duly  ob- 
served, it  exhibits  a  train  of  phenomena  peculiar  to  its  own  morbid  action; 
and  if  Peritonitis,  like  pneumonia  and  certain  other  diseases,  which  for- 
merly had  always  accorded  to  them  an  essentiality,  is  not  to  be  deemed 
an  essential  complaint — a  nosological  entity,  as  some  modern  pathologists 
maintain — it  certainly  from  its  importance  demands  a  distinct  place  in  a 
comprehensive  work  like  that  of  "  The  System  of  Medicine." 

The  other  authors  did  not  distinguish  the  inflammation  of  this  mem- 
12 


178  DISEASES    OF   THE    INTESTINES   AND    PERITONEUM. 

brane  as  apart  and  disconnected,  but  only  as  associated  and  confoanded 
with  the  inflamed  condition  of  subjacent  organs  and  tissues,  nor  was  it 
until  the  close  of  the  last  century  that  this  distinction  was  made.  Since 
that  time  the  researches  of  Broussais,  Bichat,  Barron,  Hodgkin,  and  more 
recently  of  Habershon,  have  extended  our  information,  and  given  much 
precision  to  our  knowledge  on  the  subject.  Sauvages  remarks: — Enteritis 
ineMiiterica  (Peritonitis)  dijficilllnie  distitiffuitur  ab  enteritide,  quacina 
etiam  scepe  cotfiplicatur."  '  Cullen  says  it  is  difficult  to  say  by  what  symp- 
toms it  can  be  recognized,  and  more  recent  authors  have  expressed  them- 
selves in  similar  language;  but,  as  will  hereafter  be  shown,  it  unquestion- 
ably displays  features  by  which  it  can  be  diagnosticated.  John  Hunter 
thus  delivers  himself  on  this  subject: — "  If  the  peritoneum  which  lines  the 
cavity  of  the  abdomen  inflames,  its  inflammation  does  not  affect  the  pari- 
etes  of  the  abdomen ;  or  if  the  peritoneum  covering  any  of  the  viscera  is 
inflamed,  it  does  not  affect  the  viscera.  Thus  the  peritoneum  shall  be 
universally  inflamed,  as  in  puerperal  fever,  yet  the  parietes  of  the  abdomen 
and  the  proper  coats  of  the  intestines  shall  not  be  affected."*  That  these 
propositions  are  sometimes  verfied  it  cannot  be  denied,  but  according  to 
my  own  experience  in  Peritonitis  which  has  existed  for  a  time,  it  well-nigh 
always  happens  that  some  of  the  organs  and  structures  which  it  covers 
reveal  the  inflammatory  products.  Dr.  Habershon,  in  a  valuable  article' 
on  the  etiology  and  treatment  of  Peritonitis,  speaks  with  much  boldness 
and  decision  on  this  question,  and  he  bases  his  conclusions  on  the  trust- 
worthy grounds  of  accumulated  facts.  "  In  3,752  inspections  recorded  at 
Guy's  Hospital,"  says  this  physician,  "during  twenty-five  years  500  in- 
stances of  Peritonitis  occur,  but  we  cannot  find  a  single  case  thoroughly 
detailed  where  the  disease  could  be  correctly  regarded  as  existing  solely 
in  the  peritoneal  serous  membrane."  He  then  divides  them,  firstly,  into 
Peritonitis  by  extension  from  diseased  viscera  or  direct  injury;  secondly, 
into  those  connected  with  blood  changes,  as  in  albuminuria,  pyaamia,  puer- 
peral fever,  and  erysipelas;  and  thirdly,  into  those  caused  by  nutritive 
change,  as  in  struma  and  cancer.  This  author  then  contemplates  the  af- 
fection, so-called  Peritonitis,  as  nothing  more  than  the  local  evidence  of 
antecedent  morbid  changes  pervading  the  whole  system.  Dr.  Sieveking 
says  it  is  the  climax  of  nutritive  derangements,  certainly  not  to  be  sought 
for  primarily,  in  the  serous  investment  of  the  intestines.*  The  former  of 
these  authorities  denies  that  it  is  ever  idiopathic,  but  he  would  almost  seem 
to  discard  that  term  from  pathological  phraseology,  as  he  conceives  it  can 
hardly  with  correctness  be  applied  to  any  disease  spontaneously  instituted 
within  the  organism,  and  not  dependent  upon  external  noxious  agencies  or 
parasites. 

Sometimes  the  lesion  is  but  partial,  in  other  instances  it  extends  over 
the  entire  membrane,  and  doubtless  it  is  at  the  outset  only  that  it  is  lim- 
ited, and  that  its  diffusion  gradually  supervenes.  Its  closest  analogies 
are  pleuritis  and  pericarditis,  and  like  these  affections  it  is  broadly  dis- 
tinguished by  its  tendency  to  effusion,  adhesions  by  coagulable  lymph,  or 
the  deposition  of  purulent  or  sero-purulent  fluid.  The  pathologic  condi- 
tions consequent  upon  Peritonitis,  as  of  the  other  maladies  now  in- 
stanced, are  sometimes  inceptive  of  further  disease,  or  they  may  be  de- 

'  Classis  iii.  pen.  xv.  sp.  iv. 

*  On  the  Blood,  p.  244. 

*  Medico-Chirurgical  Review,  No.  xliii. 

*  Croonian  Lectures,  Biitish  Medical  Journal,  April  14,  1806. 


PERiTOinns.  179 

fensive  against  worst  results; '  they  may  eventuate  in  the  union  or  binding 
down  of  organs  and  parts  whereby  their  functions  are  seriously  or  even 
fatally  interfered  with;  or  this  same  tendency  to  albuminous  exudation 
may,  as  in  some  instances  of  perforation,  be  conservative  of  life,  the  plas- 
tic deposit  being  the  means  whereby  nature  essays  to  effect  reparation. 
But  these  and  kindred  considerations  will  be  more  fully  considered  when 
I  speak  of  the  pathology  and  morbid  anatomy  of  the  disease. 

Etiology. — The  causes  of  Peritonitis  are  often  traceable  to  wet  and 
cold,  damp  feet,  damp  beds,  chill  winds,  sudden  alternations  of  tempera- 
ture, as  when,  after  being  in  a  heated  atmosphere,  the  body  is  rapidly 
cooled,  or  to  excessive  fatigue — in  fact  to  such  general  influences  as  are 
concerned  in  the  production  of  inflammation  in  other  viscera.  It  may,  in 
a  more  direct  manner,  be  induced — in  a  mechanical  way — by  invagination, 
strangulated  hernia,  surgical  operations  (as  in  paracentesis  abdominis, 
and  ovariotomy) ;  by  contusions,  bruises,  the  wounds  of  cutting  or  blunt 
instruments;  by  displacement  of  some  of  the  internal  organs,  or  some 
unusual  stretching  or  laceration  of  the  membrane; — by  the  extrusion  of 
certain  matters  into  the  serous  sac,  as  in  hepatic  or  splenic  abscess,  rup- 
ture of  the  stomach,  bile-ducts,  spleen,  uterus,  urinary  bladder,  ureters, 
the  ovary  or  some  part  of  the  sub-diaphragmatic  digestive  tube.  It  may 
follow  or  be  associated  with  the  acute  disease  of  some  organ  by  contiguity 
of  structure,  as  in  gastritis,  hepatitis,  splenitis,  in  dysentery,  or  in  typhoid 
fever  when  the  lower  third  of  the  ileum  or  the  vermiform  appendix  is 
ulcerated.  Sometimes  tumors,  extra-uterine  conceptions,  or  malignant 
growths  by  the  induction  of  pressure,  or  ulcerative  absorption,  give  rise 
to  it.  The  abrupt  suppression  of  habitual  discharges,  more  especially  of 
the  catamenia  and  lochia,  and  the  sudden  retrocession  of  cutaneous  erup- 
tions, have  been  enumerated;  and  contamination  of  the  blood  itself,  re- 
sulting from  the  altered  and  imperfect  action  of  certain  of  the  excreting 
organs,  enters,  there  are  good  grounds  for  believing,  far  more  frequently 
and  far  more  importantly  as  an  element  in  the  causation  than  has  hitherto 
been  supposed.  Indeed,  many  attacks  which  we  regard  as  idiopathic  are 
dependent  upon  a  common  cause  in  the  organism,  but  this  membrane  may 
sometimes  have  a  greater  proclivity  to  the  condition  of  inflammation  than 
any  other  part.  Sometimes  Peritonitis  is  metastatic  of  rheumatism,  ery- 
sipelas, and  the  exanthematous  fevers.  Broussais  repeatedly  knew  it 
succeed  intermittent  fever,  and  it  is  occasionally  connected  with  fevers  of 
a  malignant  type. 

Symptomatologt. — The  invasion  is  often  sudden,  but  the  attack  may 
come  on  slowly  and  covertly.  In  the  acute  sthenic  form  there  are  gener- 
ally rigors,  followed  by  heat  and  flushings,  a  feeling  of  lassitude,  aching 
of  the  limbs,  head,  or  back,  a  sense  of  constriction  and  uneasiness  at  the 
epigastrium,  thirst,  nausea,  and  acute  pains  at  some,  especially  the  lower, 
part  of  the  belly.  Pressure  on  the  abdomen,  coughing,  sneezing,  the 
evacuation  of  the  bladder  or  bowels,  or  even  the  erect  position,  augments 
the  pain;  indeed  whatever  produces  weight  upon  or  stretches  the  mem- 
brane, of  necessity  aggravates  the  suffering.  The  pain  is  at  first  local- 
ized, but  it  soon  becomes  diffused  over  the  entire  abdomen,  and  is  a 
prominent  sign.  As  the  disease  progresses,  the  pulse  becomes  quick, 
hard,  sharp,  and  tense,  and  rises  from  120  to  130  in  the  minute.  In  some 
exceptional  cases  it  does  not  ascend  to  more  than  80  or  90,  and  is  of  tol- 
erably full  volume;  but  as  the  rule   it  is    firm,  small,  and  cordy.     The 

^  Sir  Thomaa  Watson. 


180  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

pulse  is  not  always,  however,  a  sure  guide,  as  most  serious  attacks  may 
be  progressing  under  all  conditions  of  the  arterial  circulation;  and  even 
pain  on  pressure,  the  most  trustworthy  of  all  individual  symptoms,  is  not 
invariably  to  be  relied  upon,  because  it  is  not  uniformly  commensurate 
with  the  amount  of  lesion  which  really  obtains.  The  tongue  is  mostly 
moist  and  covered  with  a  whitish  creamy  mucus,  but  occasionally  it  is 
dry.  The  bowels  have  a  tendency  to  be  confined,  and  the  urine  is  scanty 
and  high-colored.  The  skin  is  hot  and  dry  at  the  earlier  period  of  the 
disease,  and  becomes  cool  and  bedewed  with  a  clammy  sweat  before  dis- 
solution. The  patient  lies  in  the  supine  posture  with  knees  drawn  up, 
and  cannot  turn  on  either  side  without  increase  of  pain.  He  will  say 
that  he  experiences  a  feeling  of  heat,  pricking,  cutting,  or  soreness  in  his 
inside;  involuntarily  he  relaxes  the  abdominal  muscles,  and  sometimes 
fomentations,  and  even  the  weight  of  the  bed-clothes  cannot  be  borne. 
The  breathing  becomes  quick,  shallow,  and  almost  entirely  thoracic,  and 
instead  of  being  18  or  20  it  may  be  50  or  even  GO  in  the  minute.  The 
downward  pressure  of  the  diaphragm  is  instinctively  as  much  as  possible 
avoided,  because  it  moves  the  abdominal  organs,  and  all  movement  gives 
pain.  The  passage  of  flatus  along  the  bowels  is  followed  by  the  same 
effect.  With  regard  to  the  pain,  which  is  a  cardinal  sign,  it  presents 
some  differences;  sometimes  it  is  permanent,  in  other  cases  it  is  paroxys- 
mal, assuming  a  spasmodic  character,  and  in  a  few  rare  examples  it  is  not 
present  in  marked  degree.  As  the  rule,  it  is  the  chief  and  most  reliable 
symptom. 

There  is  always  between  this  disease  and  the  features  great  sympathy. 
The  face  becomes  pale,  the  cheeks  collapse,  and  the  eyes  seem  set  and 
sunken  in  their  foramina.  It  assumes  the  Facies  Hippocratica,  or  what 
the  French  term  the  Fades  Grippee.  Nausea  and  vomiting  often  come  on 
with  the  other  symptoms,  the  ejected  matters  being  a  mucoid,  biliary  lluid; 
or,  in  the  case  of  obstructed  bowels,  the  vomited  matters  may  be  stercora- 
ceous.  Tympanitis  is  never  absent,  and  often  very  distressing.  The  loss 
of  tone  in  the  muscular  coat,  and  the  irritation  which  is  conferred  on  the 
mucous  surface  of  the  alimentary  canal,  account  for  such  condition.  The 
distention  varies  in  degree.  In  those  whose  bodies  are  flabby  and  resist- 
less it  is  often  excessive,  whilst  in  the  robust  and  muscular  it  is  in  less 
amount.  If  the  diaphragmatic  covering  becomes  inflamed,  singultus  often 
occurs;  when  the  serous  coat  of  the  stomach  is  involved,  sickness  is 
urgent;  if  that  of  the  urinary  bladder,  there  is  strangury;  and  the 
inflamed  tunic  of  the  kidneys  will  produce  ischuria  renalis.  Percussion 
elicits  the  loud  tympanitic  note,  especially  in  the  umbilical  and  epigas- 
tric regions.  When  there  is  effusion  of  serum — which,  of  course,  gravi- 
tates to  the  lower  parts  —  the  line  of  dulness  can  be  most  distinctly 
observed,  and  it  is  in  some  measure  altered  according  to  the  position  of 
the  body.  Palpation  can  only  be  had  recourse  to  with  great  care,  as  the 
extreme  tenderness  and  muscular  resistance  prevent  much  manual  exami- 
nation. When  effusion  has  taken  place,  and  coagulable  lymph  has 
matted  the  intestines  together  and  formed  roughened  deposits  on  the 
liver,  spleen,  or  some  tumor,  and  when  albuminous  concretions  adhere  to 
the  parietal  peritoneum,  the  flat  hand  laid  on  the  abdomen  feels  a  pecu- 
liar thrill  or  vibration,  which  is  most  distinct  during  inspiration.  This 
sign  only  obtains  when  the  lymph  is  thrown  out  on  a  resisting  basis. 
Auscultation  discovers  a  creaking  friction  sound,  which  is  variable  in 
character  and  intensity,  and  can  only  be  present  for  a  short  time,  as  of 
course,  on  the  advent  of  adhesion,  nothing  can  be  heard.     The  physical 


PERITOJJ^ITIS.  181 

signs  of  pericarditis  and  pleuritis  are  far  more  common.  Death  is  ushered 
in  by  quick  and  thready  pulse,  cold  and  clammy  surface,  loss  of  heat  in 
the  feet  and  legs,  accelerated  and  labored  breathing  and  general  declen- 
sion of  power,  the  mind  being  often  clear  and  collected  to  the  last.  Pem- 
berton  says  the  patient  frequently  expires  on  the  sixth,  seventh,  or  eighth 
day.  But  it  is  equally  true  that  the  fatal  issue  often  occurs  in  two  or  three 
days.  In  puerperal  Peritonitis  the  average  duration  of  the  disease  has 
been  shown  to  be  about  thirty  hours,  and  sometimes,  as  in  perforation,  it 
may  be  even  less  than  ten  hours.  When  the  affection  assumes  a  more 
chronic  form,  the  patient  may  live  so  long  as  thirty  or  forty  days. 

The  asthenic  type  of  Peritonitis  occurs  in  the  cachectic,  and  those 
■whose  vital  powers  have  been  undermined  by  some  previous  disease. 
It  is  that  form  which  is  seen  as  metastatic  of  erysipelas  and  rheumatism, 
and  in  connection  with  the  exanthems,  malignant  fevers,  puerperal 
women,  and  when  there  is  perforation  of  some  part  of  the  digestive  tube. 
It  proclaims  contamination  of  the  blood  and  want  of  vital  power.  The 
effusion  is  sudden,  large  in  quantity,  of  debased  character,  and  notably 
deficient  in  organizable  plasma.  The  pulse  is  soft  and  feeble,  the  sur- 
face soon  becomes  moist,  and  all  the  phenomena  proclaim  declension  of 
vitality. 

When  the  disease  terminates  by  resolution,  a  gradual  improvement  of 
all  the  symptoms  becomes  observable.  The  symptomatic  fever  declines, 
the  pain  is  less  urgent,  and  pressure  can  be  borne  on  the  abdomen;  the 
skin  is  moderately  moist,  but  not  below  the  ordinary  temperature;  the 
tongue  looks  cleaner;  the  pulse  is  slower,  fuller,  and  softer;  the  respira- 
tion is  more  normal,  being  less  frequent  and  not  so  thoracic;  the  aivine 
evacuations  are  freer  and  more  natural;  and  there  is  generally  a  copious 
secretion  of  urine,  which  contains  an  abundance  of  lateritious  deposits. 
Sometimes  moderate  diarrhoea  or  diaphoresis  are  critical  discharges.  The 
sickness  and  vomiting  cease,  the  tympanitis  and  feeling  of  distention 
obtain  in  less  degree,  and  the  patient  can  extend  his  legs  and  lie  on 
either  side  with  more  freedom  and  ease.  Lastly,  the  countenance,  which 
had  hitherto  been  so  faithful  an  index  of  the  complaint,  looks  calmer  and 
more  natural,  it  having  lost  much  of  the  sunken,  collapsed  appearance 
above  described. 

One  of  the  most  frequent  results  is  effusion;  indeed,  the  affection  can- 
not assume  a  well-marked  and  typical  character  without  one  or  other  of 
the  inflammatory  products  being  thrown  out,  and  these,  as  to  their  pro- 
portion and  quality,  are  varied  in  every  individual  example.  In  the  ear- 
lier stage  of  the  attack  the  effusion  is  but  small,  and  not  such  as  in 
marked  manner  to  increase  the  size  of  the  abdomen.  It  gravitates  into  the 
pelvis  and  the  iliac  fossae.  It  can  be  detected  by  percussion  over  the  lower 
parts  of  the  belly,  and  there  are  general  signs  which  indicate  its  presence. 
When  it  increases,  the  pain  becomes  a  less  prominent  symptom,  the  pulse 
is  softer,  there  is  a  feeling  of  weight  and  dragging  in  the  body,  chilliness 
and  a  diminution  of  animal  heat,  the  extremities  having  a  tendency  to 
become  cool.  In  such  cases  as  are  metastatic  of  some  other  complaint, 
the  effusion  is  much  more  rapidly  generated  and  the  serous  proportion  is 
relatively  very  large.  Andral  records  an  illustration  which  was  metastatic 
of  rheumatism,  and  which  ran  through  its  course  to  a  fatal  termination  in 
three  days,  and  the  autopsy  showed  an  enormous  quantity  of  serum 
tinted  with  the  coloring  matter  of  the  blood,  and  some  floating  flocculi 
and  false  membranes.  When  pus  is  secreted,  rigors  are  a  common  symp- 
tom, with  febrile  exacerbation  in  the  evening,  and  the  pulse  is  quicker. 


i82         DISEASES    OF   TIIE   INTESTINES    AND   PEKITONEUM. 

It  is  not,  if  in  any  notable  quantity,  absorbed.  It  finds  an  exit  either  by 
forming  an  ulcerated  opening  into  the  bowel,  which  is  always  fatal,  or, 
which  is  much  more  common,  it  establishes  a  fistulous  passage  by  way  of 
the  psoas  muscle,  or  through  some  part  of  the  abdominal  walls.  In  this 
tendency  to  appear  at  the  surface  it  seems  to  obey  the  law  of  an  ordinary 
abscess. 

Inflammation  of  the  peritoneum  rarely  ends  in  gangrene,  and  it  is  still 
more  rare  for  any  considerable  portion  of  the  membrane  to  become  gangre- 
nous. When  it  has  come  on,  it  has  generally  been  at  or  about  the  vermiform 
appendix,  or  when  some  part  of  the  bowel  has  been  unduly  stretched  or 
strangulated;  and,  according  to  Abercrombie,  it  is  invariably  accompanied 
with  false  membranes.  The  sudden  cessation  of  pain,  singultus,  coldness 
of  the  surface,  thready  compressible  pulse,  general  declension  of  strength, 
and  the  Hippocratic  countenance,  are  indicative  of  this  condition. 

Sometimes  the  acute  gradually  passes  into  the  chronic  form,  when,  as 
before  remarked,  the  patient  does  not  die  until  after  five  or  six  weeks. 
He  may  live  even  several  months.  In  such  cases  the  effusion  may  not  be 
absorbed  nor  yet  evacuated,  or  a  fistulous  communication  may  have  been 
produced,  and  all  the  conditions  of  asthenia  usher  in  the  mortal  event. 
Again,  in  other  examples,  the  serous  fluid  will  be  absorbed,  the  adhesions 
become  firm  and  organized,  or  the  sero-purulent  or  purulent  matter  be 
discharged,  and  slow  recovery  result. 

The  phases  which  the  inflammation  of  this  membrane  may  assume  are 
very  varied;  and  it  is  only  by  the  study  of  a  large  number  of  examples 
that  the  physician  can  anticipate  and  comprehend  the  modes  of  its  prog- 
ress. Sometimes  that  cardinal  symptom,  pain,  upon  which  such  emphasis 
lias  been  laid,  only  obtains  at  the  outset;  and  notwithstanding  its  subsi- 
dence, the  malady  goes  on.  Occasionally,  as  in  pleuritis,  there  may  be 
little  or  no  pain  from  first  to  last,  whilst  rigors  and  hectic  and  wasting 
pronounce  still  the  seriousness  of  the  case  at  a  time  long  after  that  period 
when  danger  is  generally  thought  to  have  passed  away,  and  a  large  col- 
lection of  pus  is  contained  in  the  cavity;  or  the  acute  symptoms  may 
rapidly  subside  under  a  properly  directed  antiphlogistic  treatment,  and 
the  condition  of  simple  ascites  will  only  appear  to  be  present;  again,  dis- 
ease instituted  in  some  of  the  abdominal  organs  will  greatly  modify  the 
affection  after  it  has  become  chronic.  In  this  state  adhesions  alter  the 
configuration  of  the  abdomen  by  large  masses  of  fibrin  being  deposited 
together,  by  the  soldering  of  the  intestinal  convolutions,  the  agglomeration 
of  one  organ  to  another,  or  by  the  formation  of  separate  collections  of 
matter  in  distinct  septa  resembling  independent  abscesses.  It  sometimes 
happens,  too,  that  the  belly  becomes  soft  and  flabby,  and,  instead  of  im- 
provement succeeding  this  disappearance  of  the  tension,  convalescence  is 
slow  and  protracted.  From  what  has  now  been  said,  it  is  obvious  that 
the  chronic  condition  is  far  from  being  uniform  in  its  phenomena,  and 
that  the  pathological  changes  may  be  diverse  and  multiform. 

Varieties. — Broussais  and  some  other  authorities  speak  of  the  induc- 
tion of  Peritonitis  by  the  exudation  of  blood  into  the  abdominal  cavity 
■without  solution  of  continuity  in  any  of  the  blood-vessels.  I  have  never 
seen  such  an  instance,  and  these  examples  must  be  extremely  rare.  Such 
sparse  exceptions  are  to  be  associated  with  the  hfemorrhagic  diathesis,  the 
predisposing  causes  being  the  sanguine  temperament  and  a  marked  ten- 
dency to  inflammatory  complaints.  According  to  Broussais,  the  pulse  is 
at  first  full,  but  soon  becomes  soft  and  compressible,  the  pain  very  acute, 
often  intermittent,  and  coldness  of  the  extremities  and  convulsions  quickly 


PERITONITIS.  183 

close  the  scene.'  Laennec  was  one  of  the  first  to  draw  attention  to  hapmor- 
rhagic  exudations  of  serous  membranes,  and  Rokitansky  attributes  such 
tendency  to  the  tubercular  cachexia,  the  diseased  condition  of  the  blood 
resulting  from  cirrhosis  of  the  liver,  the  scorbutic  constitution,  and  the 
dyscrasia  of  drunkards.  The  effect  of  specific  poisons,  such  as  induce  the 
various  febrile  diseases,  and  that  anomalous  condition  of  the  blood  now 
spoken  of  in  which  its  fibrinous  constituent  is  diminished,  and  its  serous 
part  augmented,  are  to  be  enumerated  in  the  causation  of  this  haemorrhagic 
exudation.  When  the  blood  having  this  origin  is  discovered  in  the  peri- 
toneal sac,  it  is  in  large  quantity,  very  red,  and  in  varying  proportions 
mixed  with  serum. 

There  is  another  description  of  Peritonitis  which  systematic  writers 
have  recorded,  and  to  which  the  name  of  latency  has  been  given.  It  has 
been  said  to  attack  those  laboring  under  some  other  ailment,  the  feeble 
and  attenuated,  the  aged,  the  insane,  and  such  as  exhibit  a  low  degree  of 
vitality.  Its  symptoms  at  the  outset  are  masked  and  difficult  of  recogni- 
tion, and,  when  recognized  of  the  asthenic  type,  the  features  present  those 
distinguishing  traits  before  insisted  upon  as  being  characteristic  of  this 
complaint.  It  is  evident  that  such  examples  are  nothing  more  nor  less 
than  secondary  affections  like  unto  pneumonia  in  albuminuria,  pleuro- 
pneumonia when  intercurrent  in  phthisis,  pericarditis  in  rheumatism^  and 
arachnitis  in  continued  fever. 

Non-plastic  or  Erysipelatorjts  Peritonitis. — This  is  seen  as  the  sequel 
or  complication  of  the  exanthems,  in  adynamic  fevers,  and  in  puerperal 
Peritonitis.  Its  essential  condition  is  some  h<xmic  change,  and  it  is 
characterized  by  asthenia.  It  is  met  with  in  worn-out  and  undermined 
constitutions,  in  the  unhealthy,  and  in  those  who  have  had  some  other 
malady.  Its  supervention  is  sudden,  and  it  runs  its  course  with  great 
celerity.  It  does  not  bear  an  antiphlogistic  or  lowering  treatment,  and 
is  only  benefited  by  stimulating  and  sustaining  remedies.  According  to 
Abercrombie,  *'  the  symptoms  are  sometimes  slight  and  insidious,  bul 
sometimes  very  severe;  and  they  arc  chiefly  distinguished  by  the  rapidity 
with  which  they  run  their  course,  and  by  a  remarkable  sinking  of  the  vital 
powers  which  occurs  from  an  early  period,  and  often  prevents  the  adoption 
of  any  active  treatment.  A  remarkable  circumstance  in  the  history  of 
this  affection  is  its  connection  with  erysipelas,  or  with  other  diseases  of 
an  erysipelatous  character."  *  Illustrative  of  this  form  of  the  complaint 
he  gives  the  instance  of  a  woman  who  had  erysipelatous  inflammation  of 
the  throat,  who  was  very  suddenly  seized  with  abdominal  pain  and  vomit- 
ing, and  who  gradually  sank  in  forty-eight  hours.  The  necroscopy  dis- 
covered a  large  quantity  of  pus  in  the  peritoneal  sac.  And  he  gives  other 
and  similar  examples.  This  physician  also  refers  to  an  epidemic  of  ery- 
sipelatous character  which  occurred  amongst  the  children  in  the  Merchants* 
Hospital,  Edinburgh,  in  1824.  The  disease  was  of  mild  type.  In  all  the 
cases  there  was  throat  affection,  consisting  of  a  raw,  red  appearance, 
swelling,  and  aphthous  crusts.  Two  of  the  little  patients  speedily  sank, 
and  inspection  revealed  pus  in  the  abdominal  cavity.  Abercrombie  draws 
a  comparison  between  this  epidemic  and  one  of  diphtherite,  as  it  was  then 
named,  which  appeared  two  years  afterwards,  and  he  believed  them  to  be 
congeners.  The  correctness  of  this  opinion  later  years  have  confirmed. 
Between  diphtheria  and  erysipelas  there  is  great  resemblance.     They  are 

'  Broussais,  Histoire  des  Phlegmasies  ou  Inflammations  chroniques. 

'Pathological  Researches  on  the  Diseases  of  the  Abdominal  Viscera,  3d  edit.  p.  181. 


184  DISEASES    OF   THE    INTESTINES    AND   PERITONEUM. 

both  referrible  to  general  blood  change,  and,  as  it  has  been  well  remarked, 
are  associated  with  a  large  group  of  maladies  which  stand  in  close  relation 
with  pysemia.'  The  kind  of  Peritonitis  spoken  of  occurs  with  a  depressed 
vitalism,  consequent  upon  toxaemic  agents  imbibed  from  without  or  formed 
within  the  organism  by  its  own  power  of  genesis;  and  the  term  non-plastic 
well  applies  to  the  ostensible  difference  which  there  is  between  this  type, 
deficient  in  organizable  plasma,  and  the  adhesive  form  of  inflammation. 

Perforation  of  the  Peritoneal  Membrane. — There  is  no  form  of  Peri- 
tonitis which  is  so  fearful  and  fatal  as  that  in  which  there  has  been  positiv*» 
solution  of  continuity  of  the  membrane,  because  this  accident  generally 
implies  the  extrusion  of  some  secretion  or  fluid  or  substance  into  the 
serous  cavity.  Several  of  the  older  authors  mention  this  occurrence,  and 
some  vaguely  attribute  such  openings  to  worms  —  a  possibility,  as  we 
know  from  Andral's  case,  in  which  lumbrici  passed  into  the  cavity;  but 
this  event  is  exceedingly  rare.  There  is  no  doubt  that  in  nearly  all  these 
recorded  instances  the  real  cause  of  such  perforations  was  ulcerative  de- 
struction, or  cadaveric  change,  which  former  writers  had  not  recognized 
with  that  facility  and  certitude  which  distinguish  the  acquisition  of  modern 
pathologists.  Perforation  may  be  produced  in  a  great  variety  of  ways,  by 
penetrating  wounds  made  by  sharp  or  blunt  instruments,  the  crushing 
effect  of  accidents,  lacerating  the  solid  or  hollow  viscera,  or  the  parietal 
peritoneum;  corrosive  poisons,  the  giving  way  of  the  uterine  walls  during 
parturition,  the  softening  of  a  fibrous  tumor  attached  to  the  uterus  and 
the  contents  being  extravasated ;  the  bursting  of  a  Graafian  vesicle,  of  a 
mesenteric  gland,  of  a  tubercular  deposit,  of  the  urinary  or  gall-bladder; 
from  calculi,  from  the  evacuation  of  some  collection  of  purulent  matter, 
as  in  empyema;  burrowing  through  the  diaphragm,  in  abscess,  as  before 
remarked,  of  the  liver,  spleen,  or  kidney,  in  pelvic  abscess,  and  from  other 
causes.  Mr.  Hulke  lately  recorded  an  instance  of  renal  abscess  bursting 
into  the  peritoneal  sac,  which  occurred  in  an  unhealthy-looking  maid- 
servant who  v/as  admitted  into  the  Middlesex  Hospital  for  hip  disease, 
and  which  ended  fatally.  The  inspection  discovered  puriform  serum  in 
the  peritoneal  cavity,  and  the  peritoneal  surfaces  were  coated  with  a  soft 
yellow  lymph.  The  right  kidney  was  a  mere  sacculated  pouch,  and  it 
was  ruptured  at  its  upper  end.'  The  more  common  cause  of  perforation 
is  ulceration,  commencing  in  the  mucous  membrane,  of  some  portion  of 
the  digestive  tube,  and  penetrating  through  the  muscular  and  serous  coats. 
It  may  be  referrible  to  softening  of  the  intestinal  wall  {ramoUissemefit 
ffelatiniforme),  or  to  cancerous  disease,  especially  when  the  cancerous 
deposit  encroaches  upon,  or  absolutely  blocks  up,  the  passage.  When  the 
accident  is  from  this  cause,  it  is  mostly  observed  in  the  stomach,  colon,  or 
csecum. 

The  symptoms  are  sudden,  often  violent.  Frequently  the  patient  at 
once  falls  into  collapse.  Andral  says,  that  sudden  increase  of  pros- 
tration and  rapid  change  of  the  features  are  sometimes  the  only  symptoms 
denoting  the  accident  of  perforation.  Sometimes  there  is  febrile  excite- 
ment, as  evinced  by  increased  heat  of  surface,  hard  pulse,  and  urgent 
thirst.  In  the  great  majority  of  cases  remedies  seem  inoperative;  the 
disease  rapidly  becomes  diffused  over  the  surface  of  the  sac;  whilst  vomit- 
ing, dorsal  decubitus,  quick  and  feeble  pulse,  loss  of  animal  heat,  and 
sunken  and  collapsed  features,  too  truly  indicate  the  powerful  impress 

■  Dr.  Eossell  Reynolds,  art.  Erysipelas,  vol.  i. 
•  Lanut,  Jon.  23,  1866. 


PERITONITIS.  ]R5 

•which  has  been  made  upon  the  circulatory  and  nervous  systems,  the  mental 
faculties,  generally,  remaining  unaffected  to  the  last.  In  those  very  ex- 
ceptional cases  in  which  recovery  does  take  place  the  vomiting  begins  to 
subside,  the  distention  to  decline;  the  pulse  becomes  softer,  fuller  and 
slower;  the  face  is  less  haggard,  the  patient  sleeps  more  tranquilly,  and 
the  temperature  of  the  body  is  more  natural. 

When  the  stomach  is  the  seat  of  perforation,  as  it  sometimes  is,  by 
simple  or  specific  ulcer,  the  phenomena  are  precisely  those  which  obtain 
when  any  other  part  of  the  sub-diaphragmatic  tube  gives  way.  Ulceration 
of  this  organ  is  most  frequent  in  females.  Dr.  Brinton  found  that  in  654 
cases  440  were  in  females,  and  214  in  males.  He  also  says  that  in  the 
former  sex  one-half  occurred  between  fhe  ages  of  14  and  20.'  It  happens 
to  children.  Dr.  Lee  knew  perforation  of  the  stomach  of  a  girl  of  eight, 
and  in  that  of  a  boy  of  nine  years  of  age.  The  opening  is  most  frequent  at 
the  splenic  end,  and  that  part  is  also  most  prone  to  gelatiniform  softening. 
It  may  give  rise  to  ha3morrhage.  Habershon  gives  an  example  in  which 
the  splenic  and  pancreatic  arteries  were  opened.  It  does  not  absolutely 
follow  that  death  shall  always  eventuate,  because  adhesion  may  take 
place  between  the  point  of  ulceration  and  the  abdominal  walls,  or  one  of 
the  solid  viscera,  or  a  communication  may  be  established  between  the 
stomach  and  the  colon,  or  the  duodenum,  or  a  gastric  fistula  may  be  formed 
externally,  or  through  the  diaphragm  into  the  thorax.  The  last  two 
named  are  verj'  uncommon,  but  possible  contingencies.  Abercrombie 
gives  an  example  of  the  kind  of  Peritonitis  now  considered.  A  young 
woman  had  been  affected  with  dyspeptic  symptoms  and  epigastric  pain 
for  some  months.  On  Nov.  26th,  1824,  she  was  heard  to  scream  violently, 
and  when  approached  was  unable  to  express  her  feelings  except  by  vio- 
lently pressing  her  hand  against  the  pit  of  the  stomach.  The  abdomen 
became  tender  and  distended,  and  she  continued  in  extreme  suffering  till 
the  27th,  when  she  died  twenty-nine  hours  after  the  attack.  On  the  in- 
spection of  the  body  the  cavity  of  the  peritoneum  was  distended  with  air, 
and  likewise  contained  upwards  of  eight  pounds  of  fluid  of  whitish  color 
and  foetid  smell.  There  was  slight  but  extensive  inflammatory  deposition 
on  the  surface  of  the  intestines,  producing  adhesion  to  each  other,  and  to 
the  parietes  of  the  abdomen.  In  the  small  curvature  of  the  stomach  was 
a  perforation  which  admitted  the  point  of  the  little  finger.'  This  author 
gives  another  case  in  the  person  of  an  elderly  gentleman,  who  was  suddenly 
seized  with  excruciating  pain  at  the  stomach,  accompanied  by  vomiting, 
coldness,  and  quick  pulse.  The  abdomen  became  tense  and  tender,  and 
he  sank  in  thirty  hours.  Necroscopy  exhibited  near  to  the  pyloric  open- 
ing an  ulcerated  hole  larger  than  a  shilling,  to  which  the  liver  formed  a 
base,  and  a  little  below  the  perforation  of  the  calibre  of  a  quill  through 
which  the  contents  of  the  stomach  had  escaped  and  caused  fatal  Peri- 
tonitis. 

'  Dr.  Brinton  gives  the  following  relative  proportions  per  cent,  of  the  locality  of 
perforations  whiuh  ended  fatally  by  Peritonitis  : — 

Posterior  Surface 2 

Pyloric  Sac 10 

Middle 13 

Lesser  Curvature 18 

Anterior  and  Posterior  Surface  at  once 28 

Cardiac  Extremity 40 

Anterior  Surface 85 

'Abercrombie's  Diseases  of  Stomach,  3d  edit.  p.  34. 


1S6  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

The  duodenum  is  less  liable  to  this  accident  than  the  stomach ;  but  its 
serous  tunic  does  sometimes  give  way  under  the  ulcerative  process.  Mr. 
Curling  was  the  first  to  observe  that  the  glands  of  Brunner  are  apt  to  pass 
into  ulceration  during  the  progress  of  severe  burns,  and  from  this  cause 
Peritonitis  may  in  a  secondary  manner  result.  In  twenty-two  autopsies 
made  by  Louis  in  enteric  fever,  in  only  two  cases  was  the  villous  surface 
of  the  duodenum  found  ulcerated.  In  fifteen  examples  of  that  disease  eX' 
amined  by  Jenner,  and  in  twenty  by  Murchison,  no  morbid  condition  was 
detected  in  this  organ.  Its  ulceration  in  all  its  characteristics  and  conse- 
quences very  nearly  resembled  that  described  of  the  stomach.  Haber- 
shon  says  several  cases  have  come  under  his  observation,  the  early  symp- 
toms of  the  ulceration  being  slight  until  fatal  Peritonitis  had  been  set  up 
by  perforation.  In  other  instances  violent  vomiting  produced  the  accident. 
Hodgkin  relates  the  instance  of  a  young  woman,  aged  twenty-four,  who 
was  admitted  into  Guy's  with  urgent  vomiting,  small  and  feeble  pulse, 
and  who  shortly  after  died  of  fatal  Peritonitis  caused  by  a  small  ulcer  in 
the  duodenum.  Habershon  gives  an  interesting  example  in  a  young  wo- 
man, aged  eighteen,  admitted  into  Guy's  February  19th,  and  who  died 
October  4th,  1860.  At  first  the  prominent  symptom  was  vomiting;  after 
a  time  diarrhoea  came  on,  and  the  emaciation  increased.  Examination  of 
the  body  showed  behind  the  first  portion  of  the  duodenum  and  close  to 
the  pancreas  a  collection  of  offensive  pus,  and  a  perforation  a  quarter  of 
an  inch  in  diameter  was  discovered.  From  the  histories  of  six  cases  re- 
corded by  Dr.  Andrew  Clark,'  he  concludes  that  the  event  is  sudden,  after 
food,  and  that  the  pain  never  leaves  its  place  of  origin.  In  the  examples 
given  by  this  physician  there  was  no  sensation  of  something  having  given 
way,  nor  of  heat  diffusing  itself  over  the  belly.  This  organ  is  more  fre- 
quently perforated  by  secondary  than  primary  disease.  The  malignancy 
of  neighboring  viscera  is  sometimes  extended  to  its  parietes,  as  in  cancer 
of  the  stomach,  liver,  spleen,  pancreas  and  lymphatic  glands,  and  its  con- 
sequent rupture  is  followed  by  Peritonitis,  which  ends  fatally. 

With  regard  to  the  jejunum  it  is  rarely  found  morbid,  and  assuredly 
no  part  of  the  digestive  tube  possesses  such  an  immunity  from  disease. 
I  have  known  no  instance  of  its  perforation.  Neumann  and  Hufeland, 
however,  have  recorded  an  example  of  this  event. 

Perforation  more  frequently  occurs  in  the  lower  third  of  the  ileum,  and 
near  to  the  ileo-caecal  valve,  than  in  any  other  part  of  the  intestines.  Of 
ten  cases  by  Louis,  it  was  within  a  foot  of  the  valve.  .  Of  ten  cases  given 
by  Stokes,  in  nine  it  was  within  twelve  inches  of  the  valve,  and  one  was 
in  the  cfficum.  Of  eleven  by  Murchison,  nine  were  within  twelve,  and  two 
within  eighteen  inches  of  the  same  place.  Bartlett  saw  it  forty-four,  and 
Bristowe  seventy-two  inches  from  the  same  place.  The  parts  next  in 
order  of  prevalence  are  the  csecum  and  vermiform  appendix.  Louis  was 
one  of  the  earliest  observers  of  the  facts  now  noticed.  It  has  long  been 
broadly  and  familiarly  known  that  the  agminate  glands  which  are  proper 
to  the  ileum,  and  the  solitary  glands  which  are  scattered  throughout  the 
villous  coat  of  the  digestive  tube,  are  in  enteric  fever  very  prone  to  take 
on  the  ulcerative  condition,  more  especially  the  patches  of  Peyer,  and 
occasionally  it  happens  that  after  the  mucous  and  muscular  coats  have 
been  destroyed,  the  peritoneum  gives  way.  These  glands  are  not  in  like 
manner  predisposed  to  disease  in  the  course  of  any  other  acute  affection. 
The  vermiform  appendix  has  in  repetition  been  found  the  seat  of  fatal 

>  Britiih  Medical  Journal^  June  22,  1867. 


PERITONITTS.  187 

Peritonitis,  not  only  in  enteric  fever,  when  sometimes  only  a  vcry  minute 
orifice  can  be  discovered,  but  from  the  impaction  of  some  foreign  body,  as 
the  seed  of  fruit,  a  kernel,  a  piece  of  bone,  a  piece  of  indurated  faecal 
matter,  or  even  the  single  bristle  of  a  tooth-brush.  Of  eight  cases  of  per- 
foration given  by  Louis,  seven  were  in  the  young  and  vigorous,  and  it  may 
here  be  observed  that  more  recent  writers,  as  Jenner,  Murchison,  and 
Bristowe,  have  shown  that  it  chiefly  occurs  between  the  ages  of  fifteen 
and  twenty.  Of  the  eight  cases  by  Louis,  with  a  single  exception,  the 
disease  commenced  with  continued  fever,  nor  did  the  febrile  phenomena 
assume  any  severity  of  character  until  the  advent  of  the  perforation.  In 
four  there  had  been  diarrhoea,  but  only  in  one  were  the  bowels  much  har- 
assed. Tweedie  says  the  state  of  the  bowels,  either  as  to  the  presence  or 
absence  of  diarrhoea,  is  not  to  be  depended  upon,  as  it  sometimes  happens 
that  the  evacuations  are  healthy  when  the  bowel  gives  way.  Three  were 
quite  convalescent  when  the  opening  occurred,  and  a  fourth  appeared  to 
have  fully  recovered  from  an  attack  of  enteritis. 

Since  Louis  wrote  his  account,  much  information  has  been  accumulated 
on  this  particular  subject.  It  is  now  well  known  to  all  who  have  made 
the  various  forms  of  fever  a  special  study,  that  there  is  no  precise  correla- 
tion between  the  gravity  of  febrile  symptoms  and  the  occurrence  of  per- 
foration. The  diarrhoea  may  have  been  a  distressing  and  persistent  symp- 
tom, and  yet  the  points  of  ulceration  may  not  have  been  either  numerous 
or  deep;  on  the  other  hand,  in  cases  regarded  as  mild  forms  of  fever 
the  bowel  may  very  unexpectedly  burst,  and  this  event  is  generally  at  a 
later  date  of  the  attack,  or  during  convalescence.  Tweedie  has  known  it 
take  place  when  the  patient  has  so  far  recovered  as  to  leave  the  house. 
Dr.  Murchison  lately  published  an  apt  illustration.'  Some  time  ago  I 
had  under  my  care  a  girl  in  enteric  fever  who  became  quite  convalescent, 
and  at  the  end  of  six  weeks,  after  eating  a  hearty  meal  of  solid  food.  Peri- 
tonitis supervened,  and  she  died  in  twenty-two  hours.  Peacock  saw  it 
come  on  so  soon  as  the  eighth,  and  Murchison  on  the  ninth  day  of  fever. 
Louis  noticed  it  so  late  as  the  forty-second,  and  Jenner  on  the  forty-sixth 
day.  Of  thirty-two  cases  given  by  Murchison,  perforation  occurred  dur- 
ing the  second  week  in  eight  cases;  during  the  third  week  in  six,  during 
the  fourth  week  in  nine,  and  after  the  fourth  week  in  nine.*  Louis  says, 
if  in  acute  disease,  and  in  an  unexpected  manner,  a  violent  pain  in  the 
abdomen  supervenes;  if  this  pain  is  exasperated  by  pressure  accompanied 
by  rapid  alteration  of  the  features,  and  more  or  less  promptly  followed  by 
nausea  and  vomiting,  we  may  believe  and  announce  that  there  is  perfora- 
tion of  the  intestine.'  Pain  is  not  a  symptom  in  all  cases  continuous  up 
to  death.  It  sometimes  notably  abates,  and  in  exceptional  examples  ceases 
entirely  for  several  hours  before  dissolution.  Jenner  saw  a  patient  in 
whom  there  was  no  pain  at  all,  vomiting  and  cold  extremities  being  the 
only  symptoms.  Tweedie  asserts  that  the  symptoms  of  this  event  are  not 
uniformly  well  pronounced.  The  accident  may  be  masked  by  delirium  so 
considerably  that  the  time  of  perforation  and  its  absolute  occurrence  may 
be  uncertain. 

Dr.  Stokes  gives  particulars  relative  to  nine  cases  which  occurred  under 
his  own  observation.*  These  happened  during  fever;  one  in  catarrhal 
fever,  two  after  acute  enteritis,  and  in  one  case  hypercatharsis  produced 
by  an  overdose  of  salts  was  the  cause.     In  several  of  these  nine  instances 

'  British  Medical  Journal  Dec.  2,  1865.  *  On  Fever,  p.  508. 

»  Kecherches  Anatomice-Pathologiques.  *  Cyclop.  Pract.  Med. 


188         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

there  had  been  diarrhoea.  He  also  comments  upon  a  fact  worthy  of  no- 
tice, that  in  three  were  produced  irritation  of  the  bladder  and  inability 
to  pass  urine.  In  all,  inspection  revealed  ulceration  of  the  muciparous 
glands;  and  respecting  the  time  which  the  patient  lived  after  the  initia- 
tory symptoms  of  perforation,  it  varied  from  twelve  to  one  hundred  and 
twenty  hours,  Stokes  also  says  that  the  average  duration,  deduced  from 
nineteen  cases  which  he  had  collected  from  various  sources,  was  twenty- 
nine  hours.  Louis'  patients  lived  from  twenty  to  twenty-four  hours. 
Murchison  has  known  death  follow  in  four  hours,  and  not  until  one  hun- 
dred and  five  hours.  I  have  known  it  from  seven  to  twenty-three  hours. 
The  period  subsequent  to  the  accident  must  needs  be  influenced  by  a  vari- 
ety of  circumstances,  such  as  the  character  of  the  antecedent  or  coetane- 
ous  disease,  the  vital  powers  of  the  patient,  the  extent  of  the  orifice,  and 
the  kind  and  quantity  of  lymph  thrown  out,  the  part  of  the  bowel,  and 
the  conditions  favoring  or  opposing  adhesion.  If  in  a  fever  of  the  ady- 
namic type,  when  the  powers  of  the  system  are  much  reduced,  the  shock 
may  be  such  as  at  once  to  usher  in  a  fatal  collapse.  If  the  opening  be  in 
immediate  apposition  with  another  coil  of  the  bowel,  a  solid  organ,  or  the 
walla  of  the  abdomen,  the  extrusion  of  the  contents  of  the  canal  may  for 
a  time  be  arrested.  Bristowe  relates  a  case  in  which  the  patient  lived 
fourteen  days  after  perforation.  I  remember  an  instance  in  enteric  fever 
in  which  there  was  a  hole  that  would  have  admitted  a  swan-shot  on  the 
lower  part  of  the  ileum,  but  depositions  of  pearly  lymph  had  so  effectu- 
ally sealed  up  the  opening  that  none  of  the  intestinal  contents  had  escaped. 
When,  however,  they  do  escape,  the  inflammation  becomes  so  intense  that 
remedies  are  generally  powerless.  Chomel,  Louis,  Rokitansky,  and  Jenner 
say  it  is  always  fatal.  Tweedie,  Todd,  Ballard,  Fox,  Bell,  and  Murchi- 
sou  aver  that  they  have  known  recovery.  The  last-named  relates  the  in- 
stance of  a  girl  of  sixteen,  who,  on  the  thirty-first  day  of  fever,  was  sud- 
denly seized  with  severe  pain  and  tension  of  the  abdomen,  urgent  vomit- 
ing, and  all  the  symptoms  of  collapse.  A  grain  of  opitim  was  given  every 
second  hour,  and  during  the  first  thirty-six  hours  ten  grains  were  taken. 
The  patient  made  a  tedious  recovery,  and  was  discharged  from  the  hospi- 
tal fifty-five  days  after  the  commencement  of  the  Peritonitis. 

In  some  exceptional  examples,  the  more  formidable  symptoms  will 
apparently  subside,  and  life  be  preserved  for  even  several  days.  This 
deceptive  kind  of  amendment  should  not,  however,  throw  the  physician 
off  his  guard;  he  should  not  forget  those  grave  and  alarming  indications 
which  pronounced  the  existence  of  the  accident,  as  it  almost  invariably 
j>roves  that  the  mortal  end  has  only  been  deferred,  not  averted.  In  the 
case  observed  by  myself,  if  there  was  no  absolute  escape  of  the  intestinal 
contents,  the  soft  lymphic  plug  could  not  for  any  great  length  of  timo 
have  sufficed  to  act  as  a  barrier  to  extravasation.  Some  slight  strain,  as 
in  the  evacuation  of  the  bowels,  coughing,  sneezing,  or  the  mere  motion 
of  the  body,  might  doubtless  have  been  sufficient  to  remove  the  non-organ- 
ized albuminous  deposit,  and  render  the  opening  free.  Notwithstanding 
the  well-nigh  hopelessness  of  all  cases  in  which  there  is  positive  solution 
of  continuity,  it  is  from  pathological  reasoning  a  possibility  that  recovery 
may  succeed.  Nature  attempts  to  repair  the  lesion  by  throwing  out  plas- 
tic materials,  and  if  these, — by  utter  rest,  and  by  opiates  subduing  the 
peristaltic  action  of  the  bowels, — be  allowed  to  lie  in  contact  with  the 
breach  sufficiently  long  to  become  permeated  with  new  vessels — to  be 
orffanizea — the  orifice  may  be  repaired:  such  reparation,  however,  can 
only  be  effected  when  the  hole  is  small,  and  then  it  is  but  a  mere  possibility. 


PERITONITIS.  189 

Though  the  first  symptoms  of  perforation  are  nearly  always  distinct 
and  terrible,  in  exceptional  cases  they  may  be  ill-defined  and  obscure;  or 
they  may  gradually  assume  increased  severity.  They  will  be  influenced 
by  the  size  of  the  aperture;  for  instance,  the  solution  of  continuity,  when 
it  takes  place  in  the  appendix,  is  sometimes  very  minute,  and  the  escape 
of  irritant  matters  inconsiderable.  The  orifice  may  at  first  be  small  and 
by  degrees  enlarge,  and  relatively  with  the  enlargement  (and  consequent 
greater  extravasation  of  liquid  and  faecal  contents)  will  increase  the  irrita- 
tion conferred  to  the  sac  and  the  more  manifest  phenomena  of  inflamma- 
tion. Confirmative  of  these  assertions.  Dr.  John  Harley  may  be  cited. 
"In  some  cases,"  says  this  physician,  "the  perforation  has  taken  place  so 
gradually,  the  aperture  formed  is  so  small,  and  the  extravasation  so  in- 
considerable, that  the  symptoms  of  Peritonitis  come  on  and  attain  their 
maximum  very  gradually,  and  without  any  sudden  increase  in  the  severity 
of  the  symptoms." ' 

The  colon  is  occasionally  perforated  in  fever,  but  it  is  much  less  prone 
to  this  result  than  the  parts  last  named.  Chomel,  Brinton,  Forget,  and 
Murchison  mention  five  instances.  In  two  out  of  these  cases  the  opening 
was  at  the  junction  of  the  transverse  and  descending  colon;  and  in  the 
three  others  at  the  junction  of  the  sigmoid  flexure  with  the  rectum.*  The 
last-named  authority  lately  gave  a  good  example  of  the  giving  way  of  the 
large  intestine.  "  A  young  man  of  eighteen  was  admitted  into  the  Fever 
Hospital,  Aug.  23,  1865;  he  had  been  ill  fourteen  days,  and  on  admission 
was  very  ill  of  typhoid  fever  with  Peritonitis.  The  pulse  was  quick  and 
feeble,  the  body  enormously  distended  and  tender,  the  motions  frequent 
and  watery,  and  the  breathing  thoracic.  He  died  Sept.  7.  Inspection 
discovered  the  entire  surface  of  the  peritoneum  to  be  coated  with  a  thin 
layer  of  lymph  which  could  be  stripped  off  with  a  knife.  There  were 
three  perforations  in  the  large  intestine,  one  about  three  and  a  half  inches 
below  the  valve,  and  two  in  the  sigmoid  flexure.  There  were  no  contents 
of  the  bowel  in  the  serous  sac." ' 

With  respect  to  the  average  of  perforation  in  fever,  Murchison  states 
that  out  of  435  autopsies  recorded  by  Bretonneau,  Chomel,  Montault, 
Forget,  Waters,  Jenner,  Bristowe,  and  those  made  at  the  London  Fever 
Hospital,  it  occurred  in  60  cases,  or  in  13  "8  per  cent.*  It  probably  hap- 
pens in  about  three  per  cent,  of  those  who  have  enteric  fever,  and  more 
frequently  amongst  males  than  females. 

In  chronic  dysentery,  sometimes,  after  ulceration  has  destroyed  the 
mucous  and  muscular  coats,  the  peritoneum  is  penetrated.  In  such  in- 
stances the  special  and  general  symptoms,  which  characterize  the  primary 
disease,  point  to  a  correct  diagnosis.  In  cancer  of  the  bowels  perforation 
may  occur:  it  is  more  frequent  in  the  large  than  small  intestines,  and 
Rokitansky  says  the  colon  is  almost  exclusively  the  seat  of  cancerous  de- 
generation. I  saw  in  consultation  some  time  ago  a  gentleman  laboring 
under  diffuse  Peritonitis,  which  had  evidently  been  caused  by  a  large 
hard  tumor,  the  size  of  a  cricket-ball,  in  the  left  hypogastric  region. 
The  stools  were  flattened,  but  the  passage  was  evidently  quite  patulous. 
I  gave  it  as  my  opinion  that  it  was  a  case  of  cancer  of  the  large  bowel. 
A  surgeon  was  at  this  juncture  called  in,  and  he  strangely  enough  pro- 
posed Amussat's  operation  merely  to  give  exit  to  the  flatus,  when  iarg« 
pieces  of  faecal  matter  were  voided,  but  fortunately  that  suggestion  was 

'  System  of  Medicine,  vol.  i.  p.  570.  '  Murchison  on  Fever,  p.  551. 

»  British  Medical  Journal,  Dec.  2,  18G5.  *  On  Fever,  p.  511. 


190  DISEASES   OF   TUB   INTESTINES    AND   PERITONEUM. 

overruled  by  two  of  the  most  eminent  members  of  the  profession.  In  the 
course  of  a  few  days  the  patient  died.  Perforation  was  announced  by  a 
sudden  and  terrible  increase  of  pain,  small  pulse,  sunken  features,  and 
cold  extremities.  The  autopsy  revealed  abundant  proofs  of  foregoing 
and  present  Peritonitis.  There  were  several  pints  of  serum  in  the  abdo- 
men, which  contained  loose  flocculi;  the  descending  colon  was  adherent 
to  the  abdominal  walls,  and  a  little  above  the  sigmoid  flexure  was  a 
cleanly  cut,  punched  hole,  the  size  of  a  small  pea,  through  which  a  large 
quantity  of  thin  feculent  matter  had  passed  into  the  peritoneal  sac.  The 
upper  third  of  the  rectum,  and  the  opening  into  the  sigmoid  flexure,  were 
the  seats  of  cancerous  deposit,  and  the  canal  was  patulous. 

Habershon  divides  perforations  into  two  great  classes,  those  which 
arise  from  disease  commencing  in  the  intestine  itself,  as  by  the  ulceration 
of  fever,  dysentery,  cancer,  and  the  various  forms  of  insuperable  consti- 
pation; and  those  in  which  perforation  is  from  without,  as  in  strumous 
Peritonitis,  ulceration  of  the  stomach  extending  to  the  transverse  colon, 
hydatids,  and  abscess  of  the  liver,  calculi,  abscess  in  the  other  solid  vis- 
cera or  abdominal  walls,  cancer,  extra-uterine  fcetation,  and  external  in- 
juries.' It  may  be  caused  by  laceration  of  the  gall-bladder.  Barthez 
and  Rilliet  mention  a  case  in  a  girl  of  twelve  whilst  in  fever,  and  Murchi- 
son  gives  another  instance  in  a  young  man  of  nineteen,  who  was  suddenly 
seized  with  Peritonitis  on  the  fifteenth  day  of  the  fever,  and  who  died  in 
twenty-six  hours.  It  is  rarely  observed  as  the  result  of  tubercle.  Sir 
Thomas  Watson,  in  his  large  experience,  only  remembers  a  single  in- 
stance. Of  fifty-six  cases  collected  by  Habershon,  four  only  were  from 
strumous  disease.  Jenner  once  knew  a  softened  mesenteric  gland  give 
way  during  fever,  and  Buchanan  saw  a  fatal  case  of  Peritonitis  from 
the  bursting  of  a  softened  embolic  deposit  in  the  spleen  of  a  typhous 
patient. 

Puerperal  Peritonitis. — In  the  discussion  of  this  part  of  the  subject  I 
may  here  observe  that  it  is  not  my  purpose  to  enter  upon  the  considera- 
tion of  puerperal  Peritonitis  as  it  occurs  epidemically;  but  as  I  believe 
with  many  other  writers  that  puerperal  women  are  liable  to  a  simple  form 
of  Peritonitis,  its  description  necessarily  comes  within  the  limit  of  this 
article.  Sporadic  cases  from  time  to  time  occur  without  the  diffusion  of 
the  disease,  but  even  then  it  is  right  to  observe  the  utmost  caution,  as  so 
much  doubt  is  always  involved  with  regard  to  its  contagious  nature.  In- 
flammation of  the  serous  covering  of  the  uterus  and  its  appendages  may, 
I  believe,  supervene  as  an  incidental  circumstance,  without  the  superad- 
dition  of  a  specific  poison.  The  great  effort  of  the  organism,  the  irritable 
condition  of  the  body,  after  the  exhaustion  of  expulsive  endeavors,  the 
long  distention  of  the  uterus  and  the  abdominal  walls,  and  their  sudden 
contraction;  the  friction  of  opposed  surfaces  in  the  abdomen  during 
labor,  and  the  great  excitation  given  to  the  circulatory  and  nervous  sys- 
tems, may  produce  Peritonitis.  Other  causes  operate  in  the  production 
of  this  result,  such  as  injuries  inflicted  during  instrumental  delivery,  in 
turning,  adhesion  of  the  placenta,  the  use  of  cold  affusions  in  flooding, 
and  the  improper  administration  of  stimulants.  Contamination  of  the 
blood,  originating  in  the  body  itself,  without  reference  to  external  agen- 
cies, as  when  absorption  takes  place  from  putrid  coagula  or  a  piece  of 
retained  placenta,  is  another  mode  by  which  the  malady  is  originated. 
In  uraemic  poisoning,  as  before  remarked,  the  serous  membranes  are  pre- 

'  Diaeoses  of  the  Abdomen,  2d  edit  p.  530. 


PERITONITIS.  191 

disposed  to  inflammation,  and  the  blood  vitiation  during  parturition  re- 
sembles this  cause. 

There  is,  I  need  scarcely  say,  still  much  conflict  of  opinion  relative  to 
the  real  nature  of  abdominal  inflammation  after  child-birth.  By  some  it 
is  yet  maintained  that  Peritonitis  and  puerperal  fever  are  identical — that 
these  terms  express  but  one  affection.  It  is  true  that  in  a  large  propor- 
tion of  those  who  die  of  puerperal  fever  the  peritoneum  is  inflamed,  but 
this  membrane  is  not  always  involved;  and  although  this  form  of  inflam- 
mation accompanies  this  disease  far  more  frequently  than  any  other  form, 
yet  puerperal  fever  is  something  still  more.  Of  2'22  autopsies  of  puerperal 
fever,  given  by  Tonnelli,  in  193  were  traces  of  Peritonitis;  in  29,  or  one- 
eighth,  there  were  no  traces  whatever.  Of  44  cases  examined  by  Lee, 
the  peritoneum  and  uterine  appendages  were  inflamed  in  32,  or  in  the 
relative  proportion  of  8  cases  out  of  every  11.  Dr.  Bartsch,  in  a  report 
of  the  Midwifery  Institution  at  Vienna,  records  the  morbid  appearances 
of  109  cases  of  those  who  died  of  puerperal  fever,  and  in  this  report  puerperal 
fever  is  distinguished  from  Peritonitis  and  metritis.  "  The  cases  of  puer- 
peral fever,"  he  says,  "occurred  seldom  under  the  form  of  puerperal  Peri- 
tonitis, but  generally  as  inflammation  of  the  uterine  veins,  giving  rise  to 
the  production  of  pus  in  these  vessels,  and  the  general  symptoms  accom- 
panying its  absorption."  '  Let  any  one,  says  Fleetwood  Churchill,  com- 
pare a  case  of  simple  inflammation  of  the  womb  or  peritoneum  in  child- 
bed with  a  case  of  epidemic  puerperal  fever,  their  symptoms,  course,  and 
the  effect  of  remedies,  and  I  do  not  think  a  doubt  will  remain  upon  his 
mind,  that  although  the  latter  is  a  local  disease,  it  is  not  exclusively  so.* 

The  symptoms  common  to  this  form  of  Peritonitis  may  come  on  in  a 
few  hours,  a  few  days,  or  even  so  long  as  two  or  three  weeks  after  delivery. 
Pains  and  rigors  are  generally  the  first  indications,  and  pain  on  pressure 
is  more  distinctly  felt  at  the  hypogastrium  than  at  any  other  part.  The 
skin  is  hot,  the  cheeks  are  flushed,  the  pulse  is  quick,  and  the  respiration 
hurried.  The  pain  soon  radiates  from  the  hypogastrium  into  the  iliac 
fossae,  and  then  to  the  other  parts  of  the  abdomen.  It  is  not  always 
severe,  and  is  sometimes  characterized  by  paroxysmal  attacks,  the  patient 
being  free  from  suffering  during  the  intervals;  nor  can  it  be  said  that  this 
symptom  pain  is  pathognomonic  of  puerperal  Peritonitis,  because  post 
partum  uterine  pain  may  be  urgent  when  there  is  no  co-existent  inflamma- 
tion, and  there  may  be  inflammation  with  little  or  no  abdominal  pain. 
Churchill  asserts  that  he  has  seen  five  or  six  cases  of  intense  Peritonitis 
as  proved  by  dissection,  in  which  there  was  neither  pain  nor  tenderness;  * 
and  Ferguson  records  that  he  has  known  nineteen  cases  in  which  there 
was  no  pain. 

The  abdomen  suddenly  becomes  large,  more  quickly  and  to  a  greater 
extent  than  in  any  other  kind  of  Peritonitis,  which  may  be  accounted  for 
by  the  often  relaxed  and  resistless  condition  of  the  muscular  system 
of  parturient  women,  and  because  the  abdominal  walls  have  been  so 
recently  distended.  At  the  onset  of  the  attack,  the  uterus  can  be  felt 
above  the  pelvic  brim,  soft,  flabby,  and  uncontracted,  but  as  the  distention 
obtains  in  greater  degree  it  cannot  be  distinguished.  The  lochia  are  at 
once  diminished  or  suspended,  or  their  absolute  suppression  may  precede 
the  inflammatory  phenomena.     If  the  milk  has  begun  to  flow,  its  secretion 

•  Lancet,  April  16,  1836. 

'  Diseases  of  Women,  Syd.  Soc,  p.  35. 

2  Diseases  of  Women,  5th  edit .  p.  783. 


192         DISEASES    OF   THE   INTESTINES   AND    PERITONEUiL 

is  arrested;  if  it  has  not  begun,  it  is  prevented.  If  the  mammae  ha\e 
been  full  and  rounded,  they  fall  in  and  are  flaccid  and  smaller.  The  pulse 
varies,  but  it  is  always  above,  in  the  great  majority  of  cases  greatly  above,  the 
normal  standard.  In  non-inflammatory,  uncomplicated  cases,  the  circula- 
tion may  be  accelerated,  for  a  day  or  two,  or  two  or  three  days,  but  there 
is  a  gradual  declension  of  its  frequency  from  the  time  of  delivery.  If, 
however,  after  delivery  the  pulse  shall  have  fallen  to,  or  near,  its  natural 
number,  and  it  then  suddenly  begins  to  rise,  accompanied  by  local  pain, 
higher  temperature,  thirst  and  diminished  secretions,  the  cause  is  often 
obvious. 

After-pains  may  be  confounded  with  those  of  inflammation.  They 
come  on  soon  after  delivery,  but  decrease  in  force  and  frequency  as  time 
wears  away.  Peritonitis  does  not  come  on  so  soon,  and  its  symptoms 
become  more  and  more  proclaimed,  instead  of  diminishing.  After-pains 
are  associated  with  a  firmly  contracted  uterus;  Peritonitis  with  a  relaxed 
uterus.  Remedies  which  relieve  the  former  are  useless  or  harmful  to  the 
latter.  In  the  one  affection  the  circulation  may  be  natural;  in  the  other 
it  is  never  so.  At  the  first  the  diagnosis  is  very  difficult,  because  after- 
pains  may  be  followed  by  inflammation,  and  for  a  time  the  symptoms  be 
mixed  up;  but  the  progress  of  the  case  leads  to  a  correct  conclusion. 
When  puerperal  Peritonitis  is  accompanied  with  intestinal  irritation  and 
the  inflammation  has  extended  to  the  mucous  membrane,  sickness  and 
diarrhoea  may  be  urgent.  When  the  malady  terminates  by  resolution, 
the  pain  abates,  the  tympanitis  declines,  the  pulse  becomes  fuller  and 
slower  and  softer,  the  skin  cooler  and  moist,  the  tongue  cleaner,  the  lochia 
are  re-established,  the  breasts  become  rounded  and  milk  begins  to  flow, 
the  legs  can  with  more  comfort  be  extended,  and  the  patient  can  lie  on 
her  side.  The  conditions  of  approaching  dissolution  are  —  weak  and 
thready  pulse,  varying  from  130  to  160;  the  abdomen  keeps  distended 
and  tender,  cold  clammy  sweats  come  on,  the  extremities  become  cold,  the 
breathing  is  quick,  shallow,  and  thoracic,  she  lies  on  her  back  with  legs 
drawn  up,  the  features  are  sunken,  and  the  mind  often  remains  calm  and 
clear  to  the  close. 

Perityphlitis. — This  particular  form  of  disease  has  been  more  fully 
described  by  French  than  British  pathologists,  MM.  Husson  and  Dance  ' 
give  an  excellent  account  of  the  affection;  and  it  is  also  well  described 
by  Dupuytren,  Meniere  and  Duplay.  Amongst  the  English  authors  may 
be  named  Copland,'  Syme,'  Craigie,*  Farrall,'  Burne,*  Sellar,'  and  West.* 
The  disease  originates  in  the  tunics  of  the  cajcum,  and  by  some  it  has 
been  named  pericoecal  abscess;  the  glands  or  follicles  of  this  organ  at  the 
first  become  inflamed  and  then  pass  into  the  ulcerative  condition.  The 
ulceration  of  this  part  of  the  large  bowel  may  insidiously  destroy  the 
mucous  membrane,  implicate  the  sub-mucous  cellular  tissue  an<l  })erito- 
neal  coat,  and  either  cause  inflammation  and  lymphic  adhesion  of  the  lat- 
ter, or  its  fatal  perforation.     When  agglutination  occurs  the  lesion  may 

'  M6moire  sur  quelques  Engorgements  inflammatoires  qui  Be  developpent  daos  la 
Fosse  iliaque  droite;  Repertoire  d'Anatomie,  «S;c,,  t.  iv.  p,  74.     Paris,  1827, 
'  Med.  Diet.  art.  Caecum. 

*  Principles  of  Surgery. 

'       *  Pathological  Anatomy,  2d  edit.  p.  632. 

*  Edinburgh  Medical  and  Surgical  journal,  vol,  xxxi.  p,  1.     1831. 

*  M«;dico-Chir.  Transact,  xx.  p.  20(),  and  xxiL 
''  Northern  Jmirnal  of  Medicine,  July,  1844. 

»  DiHeuses  of  Infancy  and  Childhood,  5th  edit.  p.  656.     1865. 


PERITONITIS.  193 

be  arrested.  Craigie  defines  the  malady  to  consist  in  inflammation  and 
suppuration  of  the  cellular  tissue  connecting  the  caecum  to  the  quadratus 
luinborum  muscle  and  other  parts,  or  in  inflammation  and  ulceration  of 
tiio  mucous  membrane  of  the  caecum;  and  Sellar  says  its  pathological  seat 
is  in  the  cellular  tissue  between  the  fascia  of  the  iliacus  internus  and  the 
coats  of  the  cecum. 

The  causes  of  perityphlitis  may  be  referred  to  the  peculiar  position  of 
the  cajcum,  as  well  as  to  other  circumstances.  It  is  attached  to  the  mus- 
cles of  the  right  lumbar  region,  and  its  sacculated  pouch  depends  below 
the  ileo-ca;cal  outlet,  and  as  all  physiological  anatomists  observe,  its  con- 
tents have  to  be  propelled  against  gravity;  and  it  thus  may  become  dis- 
tended with  fjccal  matters,  and  such  irritation  be  instituted  by  its  disten- 
tion and  pressure  as  to  set  up  inflammation  of  the  lining  membrane. 
Again,  hard  and  indigestible  articles  of  food,  the  stones  of  drupaceous 
fruits,  seeds,  pieces  of  bone,  and  metallic,  porcellanous,  and  vitreous 
fragments  have  been  known  to  give  rise  to  it.  The  complaint  has  in  sev- 
eral recorded  cases  been  present  long  before  its  nature  has  been  discov- 
ered. Its  earliest  conditions  are  rendered  manifest  by  the  tumescence  and 
dulness  on  percussion  at  the  right  iliac  fossa.  The  circumscribed  swelling- 
may  extend  across  to  the  umbilicus,  and  when  such  is  the  case  Peritonitis-, 
is  generally  the  accompaniment  of  other  pathologic  changes.  The  patient, 
will  complain  of  pain  at  the  upper  part  of  the  thigh,  and  this  has  not  the- 
same  freedom  of  motion  as  the  other  limb.  It  has  repeatedly  been  founci 
that  there  has  been  irregular  action  of  the  bowels,  associated  with  colicky 
pains,  which  radiate  from  the  iliac  region.  Dr.  West  says,  that  in  chil- 
dren the  bowels  are  mostly  relaxed,  and  that  pain  in  the  stomach  is  aii 
initiatory  symptom;  and  he  also  remarks,  that  the  prominence  in  the  right 
flank  sometimes  assumes  that  of  an  elongated  tumor,  which  reaches  from 
the  ramus  of  the  pubis  nearly  to  the  hypochondrium,  and  has  a  brawny 
hardness.' 

When  the  ailment  has  for  some  time  subsisted,  lymph  and  purulent 
matters  are  deposited  in  the  cellular  tissues  behind  the  cjiecum,  and  so 
long  as  the  strong  iliac  fascia  prevents  the  escape  of  pus,  a  deep  and  irreg- 
ular abscess  is  formed.  The  secretion  at  length  most  frequently  passes, 
through  the  caecal  parietes  at  the  part  uncovered  by  the  peritoneum,  as 
recorded  by  Copland,  Duplay,  and  others.  In  some  instances  it  is  infil- 
trated into  the  cellular  tissue  in  front  of  the  iliacus  internus,  and  effects 
an  exit  near  the  anus;  or  it  may  pass  into  the  folds  of  the  meso-colon,  or 
make  a  sinus  and  be  evacuated  externally,  as  in  examples  related  by  MM. 
Husson,  Dance,  and  Meniere.  Dupuytren  knew  it  extend  so  high  as  the 
right  kidney,  and  so  low  in  the  pelvis  as  to  collect  between  the  rectum 
and  bladder.  The  perityphlitic  inflammation  may  be  circumscribed  and 
rather  of  the  sub-acute  than  the  acute  type,  with  adhesion  of  adjacent  sur- 
faces. When  the  matter  perforates  the  serous  sac,  diffuse  and  fatal  Peri-- 
tonitis  ensues. 

Peritonitis  of  Children. — Acute  Peritonitis  seldom  occurs  in  infancy 
and  childhood.  It  has  been  more  frequently  observed  in  young  infants 
than  in  children  several  years  older.  Some  have  declared  it  may  affect 
the  foetus;  in  all  such  instances  syphilis  in  the  mother  has  been  regarded 
as  the  cause,  nor  is  it  improbable  that  a  general  taint  in  the  mother  should 
impart  disease  to  the  child.  Irritation  of  the  digestive  surface  is  more 
common  in  children  than  inflammation  of  the  serous  tunic.     When  Peri- 

'  Diseases  of  Infancy  and  Childhood,  5th  edit.  p.  657. 

13 


194         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

tonitis  does  occur,  it  is  generally  as  a  complication  or  sequel.  It  may 
however,  be  primary  as  well  as  secondary;  it  may  be  partial  or  general , 
acute  or  sub-acute,  and  then  pass  into  the  chronic  condition.  When  it 
appears  it  is  mostly  after  one  of  the  exanthematous  fevers;  more  especi- 
ally after  scarlatina  or  measles.  Dr.  West  has  not  known  more  than  half- 
a-dozen  instances  of  acute  general  Peritonitis  in  childhood.'  It  has  pre- 
vailed among  young  infants  when  exposed  to  deleterious  external  agen- 
cies. According  to  M.  Thore,'  at  the  Hospice  des  Enfants  Trouves,  at 
Paris,  six  per  cent,  of  the  infant  mortality  was  from  acute  Peritonitis. 
It  usually  came  as  the  complication  or  sequel  of  some  other  ailment,  and 
no  child  above  ten  weeks  was  attacked  by  it.  The  fatal  end  was  gener- 
ally before  twenty-four  hours.  Of  sixty-three  inspections  in  no  case  was 
there  pus,  but  in  all  a  greater  or  less  amount  of  serum  on  which  flocculi 
floated,  and  the  intestinal  coils  and  solid  viscera  were  adherent.  In  seven- 
teen out  of  the  sixty-three,  erysipelas  had  preceded  the  Peritonitis.  Pleu- 
ritic effusion  was  discovered  in  a  third  of  the  examples. 

The  usual  symptoms  are  pain  in  the  bowels,  which  at  first  resembles 
common  stomach-ache.  It  alternately  subsides  and  returns,  and  there  is 
mostly  diarrhoea.  In  the  course  of  a  few  days  the  pain  becomes  more 
fixed,  and  the  child  frequently  complains  of  pain  in  the  right  side,  and  if 
old  enough  he  indicates  the  locality  by  putting  his  hand  on  the  caecal  or 
umbilical  region.  The  pyrexial  phenomena  are  proclaimed,  the  little 
patient  looks  haggard,  he  is  restless  and  continually  alters  his  position; 
pressure  over  the  part  makes  him  cry,  and  the  abdominal  muscles  are 
tense.  He  lies  on  his  back,  often  with  legs  extended,  and  the  sickness  is 
not  so  urgent  as  in  the  adult.  According  to  Dr.  West,  when  the  affection 
is  of  Cffical  origin,  the  right  leg  is  often  drawn  up  and  the  left  extended. 

Dr.  George  Gregory  a  long  time  ago  described  a  form  of  marasmus, 
■which  he  believed  to  be  primarily  disease  of  the  peritoneum,  and  which  he 
conceived  to  differ  from  what  Pemberton  terms  "  irritation  of  the  intes- 
tines," and  the  kind  of  marasmus  originating  in  the  mucous  membrane.' 
From  being  met  with  in  scrofulous  children,  and  an  "  imperfect  kind 
of  pus  "  being  produced,  he  named  it  scrofulous  inflammation  of  the  peri- 
toneum. He  regarded  it  to  be  distinguished  by  abdominal  tenderness, 
shooting  pains  which  at  the  first  come  on  in  paroxysms,  but  at  length  in- 
crease in  frequency  and  violence.  The  pain  on  touch  is  first  localized,  and 
then  becomes  diffused.  Inspection  revealed  pus  and  agglutination  of  the 
viscera.  But  the  account  of  this  author  applies  more  to  chronic  than  acute 
Peritonitis.  In  acute  Peritonitis  of  children  pus  is  a  rare  consequence; 
when  it  is  formed  it  gravitates  into  the  lower  parts  of  the  abdomen,  and 
is  deposited  in  one  or  more  collections  or  septa.  It  may  be  evacuated  by 
pointing  externally,  as  in  empyema,  or  effect  an  exit  by  the  bowels,  and  it 
is  possible  recovery  may  follow,  but  such  is  a  possibility  rather  than  a 
probability.  When  it  occurs  consecutively,  as  after  some  fever,  and  when 
the  powers  of  vitality  are  lowered,  turbid  serum  with  a  few  floating  floc- 
culi is  the  common  product,  as  I  have  already  observed  when  speaking  of 
the  non-plastic  type  of  the  disease. 

Complications. — This  affection  is  often  complicated  with  some  other  dis- 
ease.    It  may  be  complicated  with  gastritis,  a  disease  which  rarely  or  never 

'  Diseases  of  Infancy  and  Childhood,  5th  edit.  p.  654. 

*  De  la  Pcritouite  chcz  les  Nouveaux-ndes,  in  the  Archives  G6n.  de  M6d.  August 
and  Reptember.  1846. 

*  iledico-Chirurg.  Trans,  vol.  xi.  p.  263. 


PERITONITIS.  195 

occurs  in  this  country  as  an  idiopathic  affection,  although  it  is  said  to  do  so 
in  warm  climates.  The  physician  will,  in  nearly  all  cases,  discover  from 
the  history  of  the  case,  or  collateral  circumstances,  the  cause  of  the  inflam- 
mation. Gastric  Peritonitis  may  be  fatal  without  the  contents  of  the  stomach 
being  poured  into  the  serous  sac,  and  without  solution  of  continuity,  espe- 
cially when  it  occurs  in  a  secondary  form.  But  in  such  examples  the  inflam- 
mation is  only  limited.  Sometimes  tumors  press  upon  the  organ  and  in- 
flame its  serous  covering,  or  the  inflammatory  condition  maybe  there  insti- 
tuted by  contiguity,  as  when  neighboring  viscera,  such  as  the  liver,  spleen, 
and  intestines,  are  thus  primarily  diseased.  Carcinoma,  especially  of  the 
pyloric  end,  will  sometimes,  by  the  mechanical  pressure,  give  rise  to  the  re- 
sult in  question;  when  this  happens  the  Peritonitis  is  generally  of  the  more 
chronic  description.  In  that  form  of  ulceration  of  the  stomach,  which  oc- 
curs mostly  in  young  women,  the  general  health  is  often  not  much  affected. 
It  is  often  in  association  with  chlorosis,  amenorrhoea,  leucorrhcea,  or  sub- 
mammary pain,  and  the  patient  is  apt  to  complain  of  a  gnawing  sensation 
at  the  epigastrium,  accompanied  with  more  or  less  of  anorexia  and  vomit- 
ing. When  the  gastric  peritoneum  is  rent  or  perforated  by  ulceration  of 
the  inner  tunics,  the  pain  is  excessive,  the  powers  of  life  are  rapidly  sub- 
dued, and  death  is  inevitable. 

When  the  peritoneum  is  inflamed  in  hepatitis  it  is  generally  in  a  par- 
tial manner,  and  it  continues  to  be  circumscribed  unless  extravasation  of 
some  description  result,  which  is  occasionally  the  case,  and  then  the  entire 
sac  at  once  assumes  the  same  morbid  condition.  Inflammation  may  begin 
in  the  parenchymatous  structure  and  extend  to  the  serous  coat,  and  when 
such  is  the  fact,  the  pain  becomes  more  acute  and  defined,  and  the  pyrex- 
ial  symptoms  are  more  pronounced.  The  right  hypochondriac  region  is 
often  full  and  tense,  the  normal  lines  of  dulness  are  extended,  there  is  pain 
on  pressure  and  deep  inspiration,  and  dyspnoea,  coughing,  and  vomiting 
are  frequent  accompaniments.  The  patient  cannot  lie  on  his  left  side,  and 
the  recti  muscles  are  rigid.  When  the  convex  surface  is  affected,  the 
diaphragmatic  investment  assumes  the  same  disease,  and  cough  is  a  promi- 
nent symptom.  The  convexity  may  be  inflamed  without  the  appearance 
of  jaundice.  When  the  concavity  is  inflamed  the  stomach  mostly  becomes 
implicated,  sickness  is  urgent,  the  gall-ducts  are  more  or  less  obstructed, 
and  jaundice,  in  greater  or  less  degree,  is  a  common  result.  When  the 
parenchyma  is  alone  inflamed,  the  pain  is  of  a  dull,  aching  character. 
When  the  serous  tunic  is  involved,  the  pain  is  sharp  and  acute.  When 
lymph  in  considerable  quantity  is  effused,  the  organ  becomes  adherent  to 
adjacent  surfaces,  and  if  the  albuminous  exudation  gravitate  to  the  lower 
part  of  the  abdomen,  agglutination  of  the  intestinal  folds  occurs.  When 
hepatic  abscess  points  to  the  surface,  partial  Peritonitis,  by  pressure,  is 
induced.  The  effused  lymph  is  protective  from  the  worse  consequence  of 
extravasation.  Hydatid  tumors  may,  like  abscess,  excite  adhesive  inflam- 
mation. Cancerous  growths  occasionally  produce  sub-acute  hepatic  Peri- 
tonitis, but  the  symptoms  are  ill-defined  and  obscure.  And  the  same  re- 
marks apply  to  the  tubercular  masses  in  the  capsule  of  the  liver. 

Sometimes  we  observe  acute  spleiiitis  as  an  intercurrent  complaint 
during  the  progress  of  intermittent  fever.  But,  as  I  have  more  fully  in- 
sisted in  the  article  on  Diseases  of  the  Spleen,  this  organ  is  infinitely  more 
prone  to  a  chronic  form  of  congestion.  Sometimes,  when  during  the  cold 
stages  the  capsule  becomes  suddenly  distended,  such  tenseness  so  stretches 
the  fibrous  and  serous  tunics  as  to  usher  in  the  inflammatory  process;  then 
pain  of  sharp  and  stabbing  character,  increased  by  pressure,  is  felt  beneath 


196         DISEASES   OF   THE   INTESTINES   AND    PERITONEUM. 

the  left  costal  cartilages  radiating  through  to  the  back ;  the  skin  is  hot, 
the  pulse  quick  and  hard,  the  urine  high  colored  and  scanty,  the  tongue 
furred,  the  bowels  are  confined,  and  if  the  under  surface  of  the  diaphragm 
has  become  affected,  cough  and  dyspnoea  are  associated  symptoms.  The 
patient  lies  partly  on  his  back  with  trunk  curved  to  relax  the  abdominal 
umscles.  Towards  evening  there  is  exacerbation  of  the  s^'mptoms.  Post- 
mortem examination  reveals  the  serous  investment  thick  and  reddened, 
and  the  organ  united  to  neighboring  parts  by  albuminous  exudation;  and 
it  is  here  not  unworthy  of  remark,  that  in  the  peritoneal  inflammation  of 
this  viscus,  cartilaginous  and  ossific  conversions  are  more  frequent  than  in 
the  peritoneal  inflammation  of  the  other  solid  abdominal  organs. 

In  enteritis,  when  all  the  coats  of  the  bowel  are  inflamed,  the  disease 
may  commence  in  the  mucous  membrane,  at  first  sickness  and  purging 
being  urgent.  In  such  cases  colicky  pains  come  on  at  intervals,  and  mod- 
erate pressure  produces  little  or  no  uneasiness,  and  at  this  stage  of  the 
malady  it  is  often  difficult  to  form  a  correct  diagnosis.  If  the  complaint 
make  progress,  if  the  skin  become  hot  and  dry,  the  pulse  quick,  the  face 
flushed,  and  pain  be  felt  on  pressure,  it  is  of  great  practical  importance  to 
distinguish  the  kind  of  lesion  to  which  the  disease  has  advanced,  because 
remedies  which  would  relieve  the  colic  would  be  absolutely  injurious  in 
inflammation.  Instead  of  diarrhoea  there  is  often  constipation;  thus  it  is 
when  mechanical  obstruction  of  the  gut  is  the  cause  of  its  being  inflamed, 
as  in  intussusception,  and  when  tumors  block  up  the  passage,  and  vomit- 
ing of  stercoraceous  matters  proclaims  the  inverted  action  of  the  boweU 
The  general  and  special  signs  of  the  peritoneum  being  inflamed  are  the 
same  as  those  above  described.  In  children  the  complaint  is  frequent 
during  dentition,  and  it  sometimes  comes  on  as  the  sequel  in  eruptive  fe- 
vers. Crude  and  indigestible  articles  of  food  in  these  little  patients  are 
often  the  cause.  Its  advent  is  marked  by  languor  and  peevishness,  the 
child  is  restless  and  complaining,  green  mucoid  stools  emitting  an  offen- 
sive odor  are  voided,  the  cheeks  become  flushed,  the  belly  tender,  and  all 
the  conditions  of  peritoneal  inflammation  are  superadded  to  a  fever  of  the 
remittent  type.  And  dissection  sometimes  exhibits  the  entire  substance 
of  a  portion  of  the  ileum  presenting  a  gangrenous  appearance  in  addition 
to  the  ordinary  products  of  serous  inflammation. 

In  nephritis — which  is  in  the  great  majority  of  instances  brought  on 
by  calculus  in  the  pelvis  of  the  kidney,  blocking  up  of  the  ureter,  some 
irritant  drug,  or  some  blow  or  external  injury — severe  pain  over  the  loins 
following  the  course  of  the  ureter  on  the  same  side,  and,  in  the  male,  re- 
traction of  the  testicle,  high-colored  urine,  and  nausea  and  vomiting  are 
common  symptoms;  and,  as  is  occasionally  the  case  when  ischuria  renalis 
supervenes,  uraemic  symptoms  are  apt  to  mask  and  obscure  the  otherwise 
more  apparent  features  of  peritoneal  complication  (perinephritis).  The 
urinary  bladder  may  be  acutely  inflamed  {cystitis),  the  inflammation  origi- 
nating in  the  mucous  membrane,  and  being  extended  to  the  muscular  and 
serous  coverings.  It  is  caused  by  calculi,  irritant  drugs,  retention,  surgi- 
cal operations,  and  external  injuries,  and  the  Peritonitis  may  be  partial  or 
general. 

Ilystitis  is  very  rarely  observed  in  the  unimpregnated  uterus;  it  may 
come  on  after  menorrhagia  by  sudden  suppression  of  the  catamenia,  long 
walks,  wet  and  cold,  and  I  have  known  it  induced  by  the  incautious  use  of 
topical  applications.  It  is  most  frequent  after  delivery,  and  the  fundus  is 
the  part  mostly  first  affected.  When  the  peritoneal  investment  becomes 
implicated  the  disease  often  assumes  an  alarming  character.     Ovaritis 


PERITONITIS.  197 

may  be  presented  in  one  or  both  the  ovaries  without  the  uterus  being  in- 
flamed; in  the  larger  number  of  examples,  howBver,  it  is  the  complication 
of  general  Peritonitis,  or  antecedent  uterine  inflammation.  Deep-seated 
pain  in  one  or  both  of  the  pelvic  cavities  indicates  the  lesion,  and  when 
the  peritoneum  is  affected  the  pain  becomes  exceedingly  acute,  and  an 
aching,  wearying  sensation  extends  down  into  the  groins  and  thighs. 
There  is  often  frequent  desire  to  micturate,  and  when  the  disease  is  con- 
tinued to  the  posterior  portion  of  the  peritoneum  the  rectum  is  rendered 
irritable,  and  there  is  constant  inclination  to  evacuate  the  bowels.  Puffi- 
ness  or  swelling  is  sometimes  seen  over  the  ovarian  region,  and  that  part 
is  most  painful  on  the  least  pressure,  and  the  sickness  and  vomiting  are 
often  distressing. 

The  comparatively  recent  establishment  of  that  great  surgical  opera- 
tion ovariotomy,  more  especially  as  practised  in  this  country,  has  proved 
that  the  peritoneal  sac  can  be  laid  open,  and  its  inner  surface  exposed 
over  a  great  extent,  and  for  a  considerable  time,  without  the  production 
of  such  fatal  results  as  it  was  formerly  believed  would  inevitably  follow. 
It  now  appears,  from  a  large  accumulation  of  cases,  that  in  a  healthy  sub- 
ject, and  especially  in  the  unilocular  tumor,  and  when  there  are  no  attach- 
ments, the  peritoneum  may  be  cut,  and  freely,  without  the  consequent 
inflammation  being  always  formidable. 

There  are  some  other  affections  with  which  Peritonitis  is  occasionally 
complicated.  In  pericarditis  and  pleuro-pneumonia  it  sometimes  happens 
that  the  inflammation  spreads  to  the  peritoneum:  but  in  such  instances  it 
is  often  extremely  probable  that  a  contaminated  state  of  the  circulatory 
fluids  constitutes  the  predisposing  cause,  and  that  the  irritation  existent 
in  one  of  the  great  cavities  is  readily  transferred  to  another,  and  that  an 
adjacent  membrane  of  similar  structure,  and  under  general  predisponent 
circumstances,  will  take  on  the  same  morbid  action.  And,  conversely,  we 
know  that  Peritonitis  often  extends  to  the  pleura,  and  it  is  not  uncommon, 
as  I  have  lately  seen,  to  find  hepatitis  associated  with  dulness,  moist  crep- 
itation, and  all  the  other  physical  signs  significant  of  inflammation  in  the 
lower  third  of  the  right  thorax;  and  when  the  spleen  is  greatly  enlarged, 
or  in  acute  splenitis,  the  same  conditions  obtain  at  the  base  of  the  left 
lung;  pressure  and  the  proximity  of  like  structures  being  the  cause  of 
such  extension.  In  empyema  the  diaphragm  may  be  rendered  convex  to- 
wards the  abdomen,  pushing  down  the  abdominal  organs,  and  friction  and 
pressure  induce  Peritonitis;  and  in  the  enlargement  of  the  liver  or  spleen, 
or  an  encysted  kidney,  or  an  ovarian  tumor,  this  partition  may  be  thrust 
up  so  abnormally  into  the  chest  as  to  press  upon  and  excite  the  pleuro- 
pulmonary  tissues  to  active  inflammation. 

Morbid  Axatomy. — The  morbid  appearances  of  Peritonitis  are  very 
various,  being  modified  by  a  number  of  circumstances;  such  as  the  type, 
the  primary  or  secondary  character  of  the  attack,  the  condition  of  the 
blood,  the  amount  and  kind  of  disease  in  the  viscera,  and  more  especially 
of  the  solid  organs. 

Before  speaking  of  inflammatory  change,  it  may  be  observed  that 
serous  membranes  may  be  simply  congested,  presenting  a  condition  analo- 
gous but  not  amounting  to  inflammation,  and  this  hyperaemic  state  may 
be  transient,  temporary,  or  long-continued.  When  often  returning  or  for 
some  time  existent  it  may  give  rise  to  excess  of  secretion,  which  is  chiefly 
serous;  nevertheless  it  may  contain  some  coagulable  matters,  but  their 
amount  will  be  dependent  upon  the  increase  or  diminution  of  the  fibrinous 
and  albuminous  constituents  in  the  blood.     Such  abnormal  afflux  of  blood 


198         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

to  this  membrane  may  subside  spontaneously,  or  there  may  be  haemorrhage 
into  the  sac,  and  such  haemorrhage  may  be  passive  or  active, — it  may  be 
by  transudation  or  rupture.  Exhalation  into  the  peritoneal  cavity  some^ 
times  occurs,  when  a  sanguinolent  serum  and  an  injected  membrane  are 
discovered.  In  visceral  laceration  considerable  collections  of  blood  of 
course  may  follow. 

The  gases  generated  in  the  cavity  of  the  peritoneum  are  sometimes  in 
great  amount;  they  are  in  nearly  all  instances  the  result  of  cadaveric 
change  and  the  decomposition  of  the  secretions.  In  empyema,  gases  aire 
produced  when  there  is  no  solution  of  continuity  in  the  pleura,  and  the 
same  may  result  when  there  is  pus  in  the  abdomen  and  the  peritoneum 
has  maintained  its  integrity;  but  they  may  have  their  origin  in  ulceration 
of  the  intestines,  or  traumatic  injury. 

The  first  inflammatory  change  in  the  peritoneum  is  the  loss  of  trans- 
parency and  of  that  shining  polished  appearance  proper  to  its  healthy 
structure.  This  dulness  or  opacity  is  accompanied  by  diminution  of  the 
lubricating  secretion,  and  Baillie,  Bichat,  and  Knox  aflBrm  that  the  mem- 
brane becomes  dry.  But  such  dryness  is  more  apparent  than  real,  because 
when  handled  it  feels  moist  and  unctuous.  The  sub-serous  vessels  become 
injected,  and  may  be  seen  through  the  fine  membrane  in  hair-like  streaks, 
arborescent  and  ramified,  or  in  a  confused  net-work,  and  when  much 
crowded  a  velvety  appearance  is  imparted.  The  degree  or  shade  of  red- 
ness depends  upon  the  period  of  congestion,  the  kind  of  inflammation, 
and  the  condition  of  the  blood.  When  the  hyperaemia  has  for  some  time 
continued,  or  in  sthenic  inflammation,  the  hue  is  light  red;  when  the  con- 
gestion is  but  recent,  or  the  inflammation  of  asthenic  type,  the  color  is 
less  vivid  and  may  be  darker  and  venoid. 

With  the  progress  of  the  disease,  vessels  in  the  membrane  which  were 
colorless  enlarge  so  as  to  admit  red-blood  globules.  At  various  points  small 
sub-serous  sanguineous  effusions  are  seen  in  the  shape  of  bloody  puncta; 
sometimes  these  are  so  numerous  as  to  exhibit  a  spotted  or  speckled  ap- 
pearance, or  they  may  coalesce  and  form  red  configurated  patches  of  vari- 
ous sizes.  I  have  said  that  at  the  first  there  is  diminution  of  the  lubri- 
cating fluid.  In  the  course  of  a  short  time  (at  periods  differing  according 
to  certain  conditions  which  obtain,  such  as  the  mildness  or  severity  of  the 
attack,  the  general  powers  of  the  system,  and  the  like)  this  secretion  is 
re-festablished,  and  if  the  malady  end  in  resolution  it  manifests  all  the 
characteristics  of  the  natural  state;  but  if  the  complaint  progress  it  is 
augmented  in  quantity  and  altered  in  quality.  The  free  surface  of  the 
peritoneum  is  then  bathed  with  a  semi-transparent  homogeneous  fluid, 
and  the  sub-peritoneal  tissue  is  surcharged  with  a  sero-albuminous  secre- 
tion, and  frequently  the  peritoneum  proper  can  be  stripped  off  with  undue 
facility.  This  infiltration,  however,  at  length  permeates  the  serous  tunic, 
when  it  and  the  filamentous  layer  become  so  confounded  that  it  is  not  easy 
to  trace  the  line  of  union.  Under  such  circumstances  the  membrane  is 
not  only  rendered  opaque,  but  it  looks  thick  and  tumefied,  and  if  carefully 
examined  it  feels  rough,  has  lost  its  lubricity,  and  close  inspection  detects 
a  viscid  albuminous  deposit  varying  in  thickness  according  to  the  duration 
and  severity  of  the  attack. 

The  new  or  morbid  secretion  which  is  effused  soon  separates  into  two 
distinct  forms, — a  thin  and  watery  whey-like  fluid,  and  a  thick  gelatinous, 
pulpy,  or  more  solid  portion;  the  former  constituting  serum,  the  latter 
coagulable  lymph,  or,  as  it  is  otherwise  named,  albuminous  exudation  or 
plasma.     The  relative  proportions  of  the  fluid  and  more  solid  parts  vary 


PERITONITIS.  199 

in  each  individual  instance.  Sometimes  we  find  no  serum  whatever,  and 
sometimes  the  effusion  consists  almost  entirely  of  serum,  the  only  traces 
of  the  albuminous  exudate  being  minute  flocculi  floating  in  the  fluid  and 
rendering  it  turbid.  In  the  inflammation  of  metastasis  and  low  types  of 
Peritonitis  the  effusion  is  sometimes  puriform  or  absolutely  purulent.  In 
acute  sthenic  Peritonitis  the  lymphic  deposit  is  great.  It  is  thrown 
down  on  the  free  surface  of  the  sac  in  various  amounts  according  to  the 
condition  of  the  circulation,  and  the  violence  of  the  inflammation.  It  may 
be  a  mere  film,  or  in  a  layer  several  lines  in  thickness.  It  differs  in  color, 
being  sometimes  of  a  grayish  red,  but  is  more  frequently  of  a  yellowish 
straw  color.  \Vhen  abundant,  it  lies  in  smooth  or  corrugated  plates;  it  is 
also  found  in  honeycomb  arrangement,  in  bands  or  bridles  constituting 
bonds  of  union  of  varying  thickness  uniting  the  viscera,  or  it  may  be  en- 
circling the  gut;  it  is  generally  seen  in  masses  filling  up  the  interspaces, 
and  when  lying  between  the  intestinal  folds  it  assumes  an  ill-defined  pri-- 
niatlc  configuration.  The  viscera  are  not  only  glued  and  matted  together, 
but  there  is  mostly  more  or  less  of  adhesion  to  the  parietal  peritoneum. 
When  a  portion  of  the  adventitious  stratum  is  detached  from  the  perito- 
neum, the  coherent  surface  of  the  new  product  exhibits  an  irregular  villous 
character,  and  it  is  speckled  with  small  bloody  puncta  produced  bv  torn 
capillaries,  and  the  sub-serous  tissue  is  ecchymosed.  The  new  formation 
being  at  first  villous,  becomes  smooth  and  more  dense,  and  at  length  assumes 
a  structure  and  qualities  analogous  to  the  true  peritoneum. 

If  the  exudation  be  submitted  to  the  microscope  new  vessels  are  seen 
to  permeate  its  substance,  and  more  especially  in  the  central  portions. 
That  they  are  connections  or  prolongations  of  the  peritoneal  capillaries  is 
beyond  dispute,  although  we  cannot  always  trace  their  continuous  struc- 
ture. It  was  believed  by  Hodgkin'  that  new  vascular  extensions  are  car- 
ried out  into  the  exudation,  and  that  subsequently  towards  the  peritoneum 
they  contract  and  become  nearly  or  quite  invisible.  This  author  is  of 
opinion  that  the  delicate  parietes  of  the  extreme  vessels  give  way,  that 
minute  quantities  of  blood  are  received  into  the  exudation,  and  that  such 
are  the  first  beginnings  of  those  minute  cavities  which  are  destined  to  be- 
come vascular. 

It  is  quite  evident  that  the  plastic  effusion  is  an  irritant  to  the  serous 
surface,  because  when  deposited  on  one  part  of  the  peritoneum,  and  any 
other  opposing  part  comes  in  contact  with  it,  such  readily  takes  on  the 
inflamed  condition;  hence  it  becomes  explicable,  in  one  way  at  least,  why 
Peritonitis  is  so  liable  to  diffusion.  According  to  the  time  which  elapses 
after  its  production,  and  the  vital  powers  of  the  organism,  is  the  degree 
or  completeness  of  the  organization.  From  being  a  semi-fluid  gelatinous 
substance  it  becomes  more  dense  and  solidified,  the  capillaries  are  more 
numerous,  it  contracts  in  bulk,  its  filamentous  texture  is  more  defined,  and 
it  enters  into  firmer  and  more  intimate  union  with  the  organs  or  parts  it 
covers  or  connects.  Where  there  is  much  motion,  it  is  sometimes  disposed 
in  a  stringy  or  reticulated  manner,  and  meshes  are  formed,  filled  with 
transparent  fluid.  Another  morbid  condition  associated  with  these  false 
membranes  is  that  of  serum  or  sero-purulent  fluid  being  collected  between 
the  peritoneum  and  the  false  formation,  until  the  latter  is  raised  up  and 
loosened  from  its  attachments  and  set  free  in  the  sac.  When  these  ad- 
ventitious membranes  remain  firm  and  adherent,  the  original  serous  mem- 
brane beneath  them  disappears,  and  their  surface  assumes  the  character- 

'  Lectures  on  Serous  and  Mucous  Membranes. 


200  DISEASES   OF   THE   INTESTINES    AND    PERITONEUM. 

jstics  of  a  veritable  serous  membrane,  and  it  is  difficult  to  distinguish  the 
new  from  the  old.  The  former  secretes  a  lubricating  serum,  is  influenced 
by  the  same  kinds  of  irritation,  is  liable  to  become  inflamed,  and  in  ita 
turn  to  throw  out  true  inflammatory  products. 

The  attachments  effected  by  these  formations  may  subsist  through  the 
remainder  of  life.  They  may  be  protective  and  conservative.  In  the  sup- 
purative stages,  when  abscess  forms  in  the  solid  viscera,  this  adhesive  in- 
flammation is  the  method  which  nature  observes  for  the  harmless  exit  of 
pus.  These  bonds  of  union  may  continue  with  little  or  no  inconvenience. 
By  the  lapse  of  time  they  become  thin  and  contracted,  and  when  health  is 
re-established  and  the  absorbents  are  active,  they  may  partly  or  wholly 
disappear.  Absorption  begins  with  the  subsidence  of  the  inflammation, 
and,  as  Rokitansky'  remarks,  it  must,  as  a  matter  of  course,  be  influenced 
by  the  thickness,  that  is  to  say  the  permeability,  of  the  deposit. 

Before  the  time  of  the  two  Hunters  it  was  not  by  pathologists  gene- 
rally allowed  that  serous  membranes  secreted  pus  without  solution  of  con- 
tinuity; in  other  words,  without  the  presence  of  ulceration.  Since  then 
this  fact  has  been  universally  acknowledged.  It  may  be  secreted  from 
the  inflamed  peritoneum,  or  from  the  surface  of  those  adventitious  mem- 
branes which  are  formed  in  the  cavity.  William  Hunter  says  it  is  gene- 
rally thinner  than  that  of  an  abscess,  and  the  containing  surface  is  more 
or  less  covered  with  a  glutinous  concretion  or  slough  of  the  same  color  as 
the  fluid,  in  some  parts  adhering  very  loosely,  in  others  so  firmly  that  it 
can  hardly  be  rubbed  off,  but  still  the  surface  covered  with  these  sloughs 
is  without  ulceration  or  loss  of  substance.*  Dupuytren  and  Villerme  be- 
lieve that  the  false  membranes  are  concrete  pus,  and  Rokitansky  is  of 
opinion  that  pus,  under  some  inherent  peculiarity,  is  a  degeneration  of 
I  plastic  exudation.  It  is  more  frequently  seen  in  the  asthenic,  sub-acute, 
and  lower  types  of  the  complaint  than  in  the  sthenic.  In  the  inflamma- 
tion of  metastasis,  when  the  blood  is  contaminated,  in  parturient  women, 
and  in  children,  it  is  most  common.  The  fluid  may  be  puriform,  purulent, 
or  sanious.  It  may  be  yellowish  green,  or  brown,  or  reddish.  The  peri- 
toneum and  sub-peritoneal  tissue  are  much  injected,  and  there  is  usually 
great  infiltration  of  the  tissues.  In  some  instances  it  appears  as  if  exud- 
ing from  the  entire  inner  surface  of  the  peritoneum ;  in  other  cases  it  is 
associated  with  adhesions,  and  is  discovered  in  distinct  collections,  bounded 
by  organized  septa,  and  resembling  separate  abscesses.  It  may  be  evacu- 
ated by  ulcerative  absorption  through  the  abdominal  parietes;  by  the  same 
process  it  may  pass  into  the  digestive  tube,  the  bladder,  or  vagina,  or 
through  the  diaphragm  into  the  thoracic  cavity,  or  effect  an  entrance  into 
the  bronchi,  or  it  may  find  a  way  of  escape  by  the  psoas  muscle. 

The  pressure  exerted  by  purulent  collections  is  doubtless  the  main 
cause  of  ulceration  commencing,  but  Craigie  believes  that  in  these  cases 
sometimes  ulceration  may  result  without  pressure,  being  merely  the  direct 
and  obvious  effect  of  inflammation.  My  colleague  at  the  Tunbridge  Wells 
Infirmary,  .Mr.  Marsack,  made  (Sept.  18,  1865)  an  autopsy  on  the  body  of 
a  young  woman,  on  whom  he  had  six  weeks  previously  performed  ovari- 
otomy. The  coils  of  the  ileum  were  welded  together,  and  joined  to  the 
abdominal  walls  by  organized  adhesions.  Between  the  layers  of  the  groat 
omentum  were  small  independent  abscesses  of  creamy  pus.  In  the  lumbar 
region  was  a  bounded  abscess-like  collection  which  contained  half  a  pint 

'  Patholoffical  Anat.,  Syd.  Soc. 

*  Medical  luquiries  and  Observations,  vol.  ii.  p.  61. 


PERITONITIS.  201 

of  pus.  At  the  sigmoid  flexure  ulcerative  perforation  was  discovered.' 
Pressure,  caused  by  a  collection  of  purulent  fluid,  had  been  followed  by 
ulcerative  absorption  of  the  tunics  of  the  large  bowel.  When  this  secre- 
tion is  eitused  in  small  quantity  it  may  be-  absorbed,  but  if  in  large  quan- 
tity and  without  opening,  irritative  fever  is  induced,  the  symptoms  of 
pyaemia  supervene,  and  it  is  then  uniformly  fatal.  Sometimes  adhesive 
inflammation  in  Peritonitis  gives  rise  to  very  peculiar  pathological  condi- 
tions. The  stomach  and  transverse  colon  have,  in  several  instances,  been 
glued  together,  and  ulcerative  absoi-ption  has  effected  a  communication 
between  them,  so  that  the  fsecal  contents  of  the  large  bowel  have  passed 
into  the  gastric  cavity,  and  thence  been  expelled  by  vomiting.  Two  or 
more  coils  of  the  ileum  may  be  soldered  together,  and  an  intercommuni- 
cating passage  established  in  the  same  manner.  In  such  examples  the 
disease  has  generally  become  chronic. 

In  the  partial  or  localized  forms  of  acute  Peritonitis,  when  some  fore- 
going visceral  disease  has  extended  through  to  the  serous  coat,  and  insti- 
tuted inflammation  in  that  tunic,  we  not  infrequently  see  circumscribed 
depositions  of  lymph  cementing  neighboring  parts  together  while  the 
remaining  extent  of  the  peritoneum  is  perfectly  healthy.  In  hepatitis, 
when  the  convex  surface  is  inflamed,  strong  adhesion  is  sometimes  discov- 
ered. The  spleen  is  in  like  manner  united  to  the  concave  surface  of  the 
diaphragm,  and  the  accretion  may  have  assumed  a  cartilaginous  or  ossific 
character,  the  latter  conversion  being  in  that  situation  more  frequently 
seen  than  in  any  other  part  of  the  abdomen.  In  simple  ulceration  of  the 
stomach  sometimes  adhesive  ulceration  averts  a  fatal  catastrophe  by 
agglutination  to  one  of  the  solid  organs,  or,  as  it  has  been  repeatedly  wit- 
nessed, by  the  production  of  an  aperture  into  the  colon,  or  sometimes 
into  the  duodenum;  and,  in  a  few  rare  instances,  a  canulous  opening  has 
been  spontaneously  made  through  the  abdominal  parietes,  forming  a  gas- 
tric fistula.  In  malignant  disease  of  this  organ,  most  frequently  seen  at 
the  pyloric  end,  there  is  much  soldering  together  of  the  adjacent  parts; 
the  peritoneum  is  opaque  and  vascular,  and  the  sub-serous  tissue  is 
greatly  injected  and  infiltrated  not  only  with  carcinomatous  deposit,  but 
also  with  serous  fluid.  The  duodenum,  as  before  remarked,  occasionally 
exhibits  partial  Peritonitis  from  rupture,  consequent  upon  ulceration  of 
the  mucous  and  muscular  coats,  as  the  result  of  extensive  burns,  but  its 
serous  investment  is  more  frequently  inflamed  from  the  irritation  and 
pressure  resulting  from  cancer  of  the  head  of  the  pancreas.  When  the 
jejunum  is  found  morbid  it  is  almost  always  in  connection  with  the  lesion 
of  other  organs.  With  regard  to  the  ileum,  what  has  above  been  said 
relative  to  the  perforation  of  its  peritoneal  covering  was  descriptive  of  its 
morbid  appearances.  In  phthisis  sometimes  protracted  colliquative  diar- 
rhoea gives  rise  to  ulceration  in  its  mucous  surface,  but  perforation  in 
phthisis  is  exceedingly  rare;  it  is,  however,  in  this  complaint  occasionally 
beheld  on  or  near  the  vermiform  appendix.  In  chronic  dysentery  the 
colon  may  give  way,  and  in  such  instances  there  is  great  destruction  of 
the  other  tunics  proper  to  the  bowel.  Such  examples  occur  in  those  who 
have  died  after  long  residence  in  tropical  climates,  and  in  association 
with  some  form  of  hepatic  disease  —  very  generally  with  abscess  of  the 
liver. 

In  puerperal  Peritonitis,  according  to  Dr.  Lee,  the  appearances  of 
inflammation  are  sometimes  confined  to  the  uterus,  but  they  are  much 


Mr.  Marsack's  Hoep.  Case  Book. 


202         DISEASES    OF   THE   INTESTINES   AND    PERITONEUM. 

more  generally  extended  to  other  organs.  The  lymph  is  mostly  thrown 
out  in  thicker  masses  upon  the  uterus  than  in  any  other  situation,  and 
this  viscus  seems  to  suffer  in  the  greatest  degree.  In  the  sub-serous  cel- 
lular tissue  serum  and  pus  are  often  deposited.  The  cellular  tissue  sur- 
rounding the  vessels  of  the  uterus  where  they  enter  and  quit  the  organ, 
and  that  connecting  the  muscular  fibres,  is  often  surcharged  with  serum 
and  purulent  fluid.'  The  peritoneum  becomes  thick  and  vascular,  more 
especially  where  it  invests  the  uterus  and  pelvic  viscera,  and  sometimes, 
when  the  malady  is  intense,  the  serum  is  mixed  with  blood,  and  pus  is 
found  in  the  pelvis.  When  death  has  rapidly  followed,  the  lymphic  exu- 
date is  semi-fluid,  or  the  surfaces  which  have  become  agglutinated  are 
readily  torn  asunder.  The  Fallopian  tubes  and  ovaries  are  sometimes 
filled  with  pus  or  blood. 

In  the  Peritonitis  of  children  the  abdominal  viscera  are  found  matted 
together  and  adherent  to  the  abdominal  walls.  In  some  cases  the 
viscera  are  covered  with  a  thin  grayish  opaque  covering,  which  feels  soft 
and  unctuous,  and  a  turbid,  reddish  serum  in  which  small  flocculi  are 
floating  is  effused  in  varying  quantity.  In  that  strumous  affection  which, 
according  to  Gregory,  gives  rise  to  Peritonitis,  pus  is  secreted.  And 
this  physician  asserts  that  sometimes  the  abdominal  cavity  will  be  abol- 
ished, the  viscera  being  united  in  one  mass,  and  everywhere  adherent  to 
the  parietal  peritoneum,  the  latter  in  all  its  duplications  being  thickened, 
and  the  soldered  intestinal  convolutions  inter-communicating.*  When 
the  peritoneum  becomes  inflamed  consecutively  after  scarlet  fever, 
measles,  rheumatism,  or  some  other  fever,  an  excess  of  serous  effusion  is 
discovered,  the  albuminous  portion  being  inconsiderable  or  almost  absent. 
The  fluid  is  of  whitish  straw-color  or  of  dirtyish  red. 

DiAGKOsis. — The  more  severe  forms  of  acute  Peritonitis  are  fully 
expressed,  and  the  disease  cannot  well  be  mistaken;  but  in  the  sub-acute 
and  more  partial  descriptions,  when  the  disease  is  not  a  primary  but 
secondary  complaint,  or  a  complication,  it  may  be  so  masked,  mixed  up, 
and  confounded  with  the  symptoms  of  other  morbid  changes  as  to  render 
the  diagnosis  very  difficult.  In  all  instances  the  physician  should  pay 
marked  attention  to  the  history  of  the  case,  as  well  as  to  the  objective 
and  subjective  symptoms,  because  there  are  affections  which  when  super- 
ficially reviewed  simulate  this  complaint,  and  it  has  not  infrequently  hap- 
pened that  the  ignorant  or  off-hand  practitioner  has  fallen  into  grave 
error.  The  diseases  which  it  most  resembles  are  gastritis,  enteritis,  colic, 
rheumatism,  neuralgia,  hysteria,  obstruction  of  the  gall-ducts,  renal  calcu- 
lus, and  lead-poisoning.  With  respect  to  gastritis,  it  is  in  this  country, 
as  I  have  before  observed,  rarely  or  never  met  with  as  a  purely  idiopathic 
affection.  Abercrombie  means  by  this  term  inflammation  of  the  mucous 
membrane,  and  it  is  in  such  sense  that  it  is  now  employed.  When  the 
mucous  coat  takes  on  this  morbid  state  there  may  be  pain  on  deep  pres- 
sure, the  sickness  is  urgent,  the  thirst  distressing,  and  fluids  are  con- 
stantly ejected.  It  can  almost  always  be  traced  to  some  exciting  cause. 
In  Peritonitis  there  is  more  difficulty  in  the  etiological  conclusion,  and  in 
the  latter  the  pulse  is  smaller  and  more  wiry.  The  inflammation  may 
commence  in  the  digestive  surface  and  extend  to  the  peritoneal  invest- 
ment, and  it  then,  of  course,  becomes  partial  Peritonitis.  It  occasionally 
occurs  when  the  gastric  portion  of  the  peritoneum  is  roughened  by  lym- 

'  More  Important  Diseases  of  Women,  p.  24. 
'  Medico-Ghirurg.  TranBactions,  vol.  xL  p.  266. 


PERITONITIS.  203 

phio  exudations  that  auscultation  can  detect  some  friction  sound;  buv 
this,  however,  is  seldom  heard.  In  the  great  majority  of  cases  gastritis  is 
referrible  to  acrid  and  corrosive  poisons.  Haller  knew  it  produced  by  the 
patient  having  taken  cold  water  when  he  was  heated.  It  is  frequently 
very  difficult,  often  absolutely  impossible,  to  diagnose  Peritonitis  from 
enteritis.  Inflammation  may  begin  in  the  mucous  membrane  and  impli- 
cate the  peritoneum,  or  Peritonitis  may  at  length  involve  all  the  coats  of 
the  bowel,  when  both  diseases  obtain.  The  vomiting  is  more  urgent  in 
enteritis,  the  bowels  are  often  obstinately  obstructed,  and  gangrene  is 
sometimes  the  result.  The  pulse  is  of  better  volume  than  in  Peritonitis, 
and  as  the  rule  the  patient  does  not  complain  of  so  much  pain.  In  Peri- 
tonitis, partly  owing  to  the  involution  of  the  parietal  peritoneum,  the 
pain  on  pressure  is  more  acute  and  superficial,  the  patient  is  more  averse 
from  motion,  the  respiration  is  more  thoracic,  and  the  features  are  more 
collapsed. 

In  colic,  which  may  be  from  simple  flatulence,  the  pain  and  distention 
may  be  severe,  and  even  the  face  may  be  an  index  of  suffering.  When  there 
is  very  great  distention  pressure  may  increase  the  pain,  but  more  com- 
monly pressure  relieves  rather  than  augments  it;  the  circulation  is  little 
if  at  all  affected,  and  there  is  no  symptomatic  fever.  Frequently  consti- 
pation and  vomiting  are  associated  with  other  symptoms;  the  patient 
complains  of  a  twisting,  wringing  pain  at  the  umbilicus,  which  comes  on 
paroxysmally,  and  there  are  intervals  when  the  suffering  is  inconsiderable 
or  absent.  This  condition  of  colic  is,  when  regarded  alone  and  as  simple 
colic,  not  an  important  affection,  but  it  sometimes  comes  on  as  the  herald 
of  a  more  grave  disease,  and  ends  by  the  development  of  inflammatory 
symptoms.  In  colica  pictonum  there  is  no  apparent  obstruction  of  the 
bowels,  although  there  are  the  common  symptoms  of  ordinary  colic.  There 
are  constipation  and  abdominal  pain,  even  violent  pain — dolor  atrox — but 
there  are  other  symptoms,  such  as  pain  in  the  head  and  limbs,  a  blue, 
leaden  line  in  the  gums,  and  loss  of  power  in  the  hands  and  fore-arms, 
and  the  patient  is  either  a  painter,  or  investigation  discovers  that  he  has 
in  some  way  been  subjected  to  lead  poisoning.  The  abdominal  muscles 
in  rheumatism  sometimes  are  rendered  so  excessively  painful  that  moder- 
ate pressure  causes  great  suffering,  and  notwithstanding  that  examples 
are  occasionally  observed  in  which  acute  Peritonitis  has  thus  supervened, 
yet  such  instances  are  very  exceptional,  and  ordinary  observation  will 
generally  prevent  any  mistake  in  diagnosis.  Negative  facts  will  be  our 
chief  guide.  In  such  cases  the  circulation  is  little  affected,  the  pulse  is 
large  and  full  but  not  frequent,  sickness  and  vomiting  are  not  present, 
the  countenance  has  not  the  pinched,  anxious  expression  which  it  assumes 
when  the  peritoneum  is  inflamed,  and  if  the  abdomen  be  carefully  examined 
the  tenderness  will  be  found  more  severe  at  the  origins  and  insertions 
of  the  muscles;  lastly,  it  will  be  shown  upon  inquiry  and  examination 
that  rheumatism  has  recently  obtained,  or  that  its  symptoms  are  still 
present  in  other  parts  of  the  body. 

Neuralgia  is  another  affection  which  mimics  Peritonitis.  The  pain  is 
described  as  a  tight  girdle  or  ligature  passing  round  the  body,  and  impart- 
ing a  feeling  of  constriction ;  it  traverses  the  course  of  the  genito-crural 
nerve,  percussion  on  the  spinal  processes  detects  some  tenderness,  and  the 
legs  and  genito-urinary  organs  are  often  more  or  less  affected;  again, 
there  is  the  absence  of  tympanites,  pain  on  pressure,  quick  pulse,  facial  col- 
lapse, and  other  phenomena  so  expressive  of  Peritonitis,  and  which  I  have 
in  detail  described  above.     In  that  protean  malady  hysteria,  which  mocks 


204         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

this  as  it  simulates  so  many  other  affections,  the  patient  is  apt  to  complain 
of  increased  pain  almost  before  the  hand  has  really  touched  the  abdomen 
and  when  it  does  touch  it,  the  pressure  does  not,  as  in  Peritonitis,  augment 
it.  The  pulse  is  natural,  the  tongue  clean,  and  the  countenance  does  not 
bear  the  impress  of  severe  and  acute  disease.  The  breathing  is  not  thoracic, 
the  legs  can  be  extended,  the  decubitus  is  not  dorsal,  and  borborygmi  and 
intestinal  flatulence  are  often  present;  again,  upon  inquiry,  it  will  not 
infrequently  be  found  that  large  quantities  of  pale  or  colorless  urine  have 
been  voided,  that  the  uterine  functions  are  at  fault,  or  that  some  ill-defined 
spinal  symptoms  obtain.  A  comparison  of  the  leading  features  common 
to  the  two  affections  will  leave  but  little  doubt  as  to  the  true  nature  of 
the  ailment. 

In  obstruction  of  the  gcdl-ducts  irom.  calculi,  inspissated  gall,  tumors, 
spasm,  and  other  causes,  the  pain  is  paroxysmal,  often  excruciating;  and 
with  the  passage  of  the  obstructing  body,  and  the  restored  patency  of 
the  canal,  the  suffering  at  once  subsides.  There  is  no  pyrexia,  the  heart's 
action  is  little  or  not  at  all  accelerated,  nor  is  there  distention  or  abdom- 
inal tenderness.  In  addition  to  such  negative  there  are  positive  facts; 
the  symptoms  of  biliary  disturbance  are  mostly  present,  the  alvine  de- 
jections are  often  light-colored,  the  urine  is  dark  and  porter-like,  the  con- 
junctiva3  are  yellow,  the  skin  is  tawny,  and  the  pain  is  localized  beneath 
the  margin  of  the  right  false  ribs.  In  renal  calculus  the  pain  radiates 
from  the  back  round  to  the  abdomen,  it  comes  on  suddenly,  courses  down 
the  direction  of  the  ureters,  in  the  male  produces  retraction  of  the  testicle 
of  the  same  side,  and  shoots  down  the  thigh,  when  for  a  shorter  or  longer 
interval  it  declines  or  entirely  subsides,  and  bloody  urine  is  a  common 
accompaniment. 

In  puerperal  Peritonitis  the  after-pains  are  associated  with  contracted, 
not  relaxed  uterus,  which  is  the  fact  in  Peritonitis;  they  gradually  dimin- 
ish, and  in  thirty  or  forty  hours  have  become  much  less  in  force  and  fre- 
quency. Inflammation  of  the  peritoneum  commences  at  the  ordinary  date 
of  the  after-pains'  decline.  The  remedial  agents  which  relieve  hysteralgia 
do  not  arrest  acute  Peritonitis.  Ephemeral  fever  is  distinguished  by  its 
brevity,  its  milder  aspect,  by  the  mammje  remaining  of  normal  size,  and 
those  serious  conditions  which  mark  the  advent  of  an  inflamed  peritoneum 
are  wanting.  Lastly,  in  speaking  of  the  diagnosis  of  this  affection,  it  must 
be  borne  in  mind  that  under  grave  cerebral  disease,  when  nervous  sensi- 
bility is  obtunded,  the  peritonitic  symptoms  may  be  rendered  very  obscure, 
and  under  such  conditions  diagnosis  may  be  impossible. 

Prognosis. — The  opinion  to  be  arrived  at  relative  to  the  result  of  this 
disease  will  be  modified  and  determined  by  a  variety  of  considerations,  and 
in  every  case  a  different  array  of  facts  will  be  presented,  all  the  bearings 
of  which  should  be  carefully  scanned.  The  asthenic  is  less  auspicious  than 
the  sthenic  type,  and  when  it  is  the  inflammation  of  metastasis  the 
chances  of  recovery  are  less.  In  unfavorable  cases,  in  despite  of  the  best- 
ordered  means  of  treatment,  there  is  a  progressive  aggravation  of  all  the 
cardinal  symptoms;  the  pain  does  not  decline,  nor  do  the  distention  and 
the  tenderness  abate;  the  breathing  is  more  hurried,  shallower,  and  en- 
tirely thoracic,  the  pulse  becomes  thready  and  intermittent,  the  sickness  is 
excessive,  the  bowels  are  generally  confined,  distressing  singultus  super- 
venes, the  surface  becomes  cool,  is  clammy  and  relaxed,  the  legs  and  feet 
are  cold,  the  patient  falls  down  in  bed  with  knees  drawn  up,  lies  on  his 
back,  the  Hippocratic  countenance  is  more  marked,  and  often  the  mind  is 
clear  to  the  end.     He  sinks  by  asthenia.     In  those  instances  when  we  can 


pERrroNins.  205 

prognosticate  k  favorable  termination,  there  is  remission  of  pain  and  ten 
deniess,  decline  of  the  distention,  the  sickness  comes  on  at  longer  inter- 
vals, and  at  length  abates;  the  pulse  is  slower  and  fuller,  the  temperature 
of  the  body  equable  and  warm,  the  respiration  is  not  so  quick,  and  the 
diaphragm  descends  lower  down,  and  the  patient  can  turn  on  his  side. 
When  we  have  reason  to  believe  that  there  is  perforation  of  the  bowel, 
rupture  of  the  liver  or  spleen,  the  urinary  or  gall-bladder;  when  we  sus- 
pect the  evacuation  of  an  abscess  or  the  effusion  of  blood,  our  prognosis 
must  be  unfavorable,  and  recovery  under  such  conditions  is  well-nigh 
hopeless.  In  the  consecutive  form,  when  the  strength  has  been  under- 
mined by  a  previous  malady,  the  probabilities  of  a  fatal  issue  are  great. 
In  puerperal  Peritonitis  antecedent  haemorrhage  and  the  amount  of  ex- 
haustion induced  by  parturient  efforts  would  influence  our  decision. 

Treatment. — In  every  example  of  acute  peritoneal  inflammation,  the 
remedies  should  be  prescribed  with  a  just  reference  to  the  emergencies  of 
each  particular  case,  because  no  trite  and  exact  rules  can  be  given  admissi- 
ble of  universal  application.  The  date  of  the  disease,  the  powers  of  the 
patient,  the  kind  of  pathologic  action  going  on,  and  the  antecedent  cir- 
cumstances so  far  as  they  can  be  ascertained,  in  conjunction  with  other 
facts,  must  needs  modify  our  resources,  and  be  suggestive  in  the  selection 
of  those  agents  which  are  accounted  as  the  most  effective  auxiliaries  in 
combating  the  affection.  That  this  disease,  like  many  other  ailments, 
when  seen  at  the  outset,  and  treated  according  to  science  and  experience, 
can  be  guided  and  carried  to  a  successful  termination  is  of  such  every-day 
proof  as  not  to  require  being  insisted  upon  here.  And  on  the  other  hand, 
if  its  progress  be  unrestrained  by  ignorance  or  timidity,  it  soon  passes  be- 
yond the  control  of  the  most  vigorous  handling  and  the  nicest  skill.  It  is 
eminently  one  of  those  complaints  which  does  not  admit  of  vacillation  and 
delay,  promptitude  and  decision  of  purpose  being  of  paramount  importance. 

In  an  acute  attack  of  inflammation  of  the  sthenic  type,  in  the  strong 
and  hitherto  healthy,  and  especially  those  who  have  lived  in  the  pure  air 
of  the  country,  our  best  ally  is  blood-letting j  but  it  is  by  far  the  most  suc- 
cessful when  performed  at  the  commencement  of  the  malady — as  soon  as 
possible  after  the  pulse  has  become  hard  and  quick,  the  pain  urgent,  and 
the  disease  established.  It  is  then,  by  making  a  decided  impression  upon 
the  circulating  organs,  that  there  is  the  greatest  chance  of  the  inflamma- 
tory action  being  cut  short,  and  of  those  morbid  processes  being  arrested 
which  so  quickly  follow  the  development  of  the  affection.  Nor  should  we 
be  deterred  from  the  use  of  the  lancet  by  the  mere  smaUness  of  the  pulse, 
because  it  may  feel  constricted,  hard,  sharp,  wiry  under  the  finger,  for  with 
the  free  emission  of  blood  it  will  increase  in  volume  and  become  soft  and 
more  natural  to  the  touch.  Many  authorities,  and  some  of  high  reputation, 
have  spoken  of  the  number  of  ounces  which  ought  to  be  drawn  at  a  first, 
second,  or  even  third  depletion,  but  there  is  no  just  rule  as  regards  quan- 
tity. One  patient  will  bear  a  much  greater  loss  of  blood  than  another, 
even  when  the  two  cases  seem  to  bear  a  close  resemblance.  Our  real  and 
only  reliable  guide  must  be  the  effect  produced  by  the  abstraction.  An 
influence  must  be  made  upon  the  heart's  action,  and  the  patient  should,  if 
possible,  be  bled  in  the  erect  position.  Abercrombie  recommends  one  or 
two  small  bleedings  at  short  intervals  after  the  first  in  order  to  keep  up  the 
good  results  of  the  primary  depletion.  There  is  no  doubt  if  ten  or  a 
dozen  hours  are  allowed  to  elapse  after  the  first  use  of  the  lancet,  and  be- 
fore a  second  visit,  that  in  such  long  interval  the  pulse  may  recover  its 
strength,  the  initiatory  symptoms  in  full  force  return,  and  a  larger  quan- 


206  DISEASES   OF   THE   INTESTITTES    AND    PERITONEUM. 

tity  of  blood  will  require  to  be  lost.  In  a  disease  so  perilous  the  patient 
should  at  the  outset  be  seen  every  two  or  three,  or  at  least  every  three  or 
four  hours.  It  is  within  the  first  twenty-four  hours  that  blood-let- 
ting is  of  -the  most  avail.  When  effusion  has  set  in  and  progressed  to 
some  extent,  blood-letting  is  more  likely  to  be  harmful  than  useful.  In 
the  young  and  the  robust,  in  those  of  ruddy  complexion  and  high  arterial 
action,  and  those  who  live  in  the  purer  air  of  the  country,  bleeding  is 
much  better  borne,  and  it  may  need  to  be  repeated.  The  dwellers  in 
urban  communities,  especially  amongst  the  badly  nourished  and  ill  clad, 
such  as  present  themselves  at  the  hospitals  of  the  metropolitan  cities  and 
large  towns,  very  rarely,  if  ever,  require  general  blood-letting,  and  when 
it  is  had  recourse  to,  a  smaller  quantity  is  followed  by  the  desired  effect. 

After  the  lancet  has  been  used  it  is  excellent  practice  to  follow  it  up 
by  local  depletion.  Cupping  is  of  course,  from  the  pressure  it  would  give, 
inapplicable;  but  twenty,  thirty,  or  even  forty  leeches  at  one  time  may  be 
applied  to  the  abdomen,  and  often  with  the  greatest  benefit.  Fomentations, 
by  means  of  flannels  immersed  in  hot  water,  and  wrung  out  as  dry  as  pos- 
sible, the  heat  and  moisture  being  kept  up  by  their  being  covered  with  a 
large  piece  of  oiled  silk,  is  good  treatment,  and  the  flow  of  blood  can  thus 
for  some  time  be  promoted;  or  a  large  linseed-meal-and-bread  poultice,  or 
a  bran  poultice,  produces  a  soothing  effect.  In  the  use  of  these  applica- 
tions, however,  care  should  be  taken  to  constantly  renew  them  before  they 
become  cool,  and  when  they  are  discontinued  a  dry  hot  flannel  of  three  or 
four  folds  should  be  placed  upon  the  abdomen.  Another  very  valuable 
mode  of  treatment  at  this  juncture  is  the  employment  of  terebinthinate 
epithems.  Two  or  three  dessert-spoonfuls  of  the  spirits  of  turpentine  may 
be  sprinkled  over  the  wet  flannel,  or  a  large  piece  of  spongio-piline  the 
size  of  the  abdomen  may  be  wrung  out  of  hot  Avater,  and  the  turpentine  in 
like  manner  sprinkled  over  it;  and  these  may  be  repeated  two  or  three 
times  if  the  patient  can  endure  the  applications.  I  can  bear  testimony  to 
the  very  excellent  effects  of  the  external  use  of  turpentine,  which  I  have 
very  frequently  in  this  mode  recommended,  and  I  believe  it  to  be  a  most 
valuable  remedy. 

The  late  Dr.  Sutton  of  Greenwich  was  the  advocate  of  cold  applica- 
tions in  abdominal  inflammation.  He  used  cold  enemata,  and  cold  cloths 
made  wet  with  evaporating  lotions,  and,  as  he  asserted,  with  great  bene- 
fit. Abercrombie  also  recommends  this  method  of  treatment.  "  In  a  con- 
siderable number  of  cases,"  says  this  physician,  "  I  have  used  with  evi- 
dent advantage  the  application  of  cold  by  covering  the  abdomen  with 
cloths  wet  with  vinegar  and  water,  or  even  iced  water.  Injections  of  iced 
water  have  been  proposed,  and  I  think  it  probable  might  be  used  with 
advantage." '  M.  Smoler  of  Prague  has  recommended  cold  compresses 
often  renewed,  and  laid  on  the  abdomen,  their  application  being  desisted 
from  as  soon  as  the  patient  sleeps;  but  he  never  allows  the  patient  to 
change  them  with  his  own  hands.'  Not  having  any  personal  experience 
of  cold  appliances,  I  shall  therefore  not  do  more  than  mention  a  remedy 
to  the  success  or  otherwise  of  which  I  can  bear  no  testimony.  It  would 
to  myself  at  least  seem  of  doubtful  utility  in  many  cases,  and  one  involv- 
ing great  risk  in  others,  and  I  prefer  what  I  believe  to  be  equally  effica- 
cious, and  certainly  safer,  namely,  warm  fomentations. 

After  the  abstraction  of  blood  a  large  dose  of  opium  should  at  once 

'  Pathological  and  Practical  Researches.  3d  edit.  p.  173. 
'  Betz's  Memorabilien,  andGaz.  Med.  Lyon,  Nov.  1(5,  1865. 


PERITONITIS.  207 

bo  administered,  and  two  or  three  grains  may  be  given  in  urgent  cases. 
It  then  not  infrequently  happens  that  the  patient  has  a  tranquil  sleep, 
after  which  he  awakes  with  less  pain,  a  moister  skin,  and  with  remission 
of  the  symptoms  generally.  In  those  instances  in  which  sickness  and 
vomiting  from  time  to  time  come  on,  opium  often  acts  more  beneficially. 
If  we  wish  to  influence  the  system  by  mercurials,  one  grain  of  opium  and 
three  grains  of  calomel  may  be  taken  every  four  or  six  hours,  and  mercu- 
rial frictions  on  the  thighs  and  in  the  axillse  can  at  the  same  time  be 
adopted  by  means  of  the  linimentum  hydrargyri,  which  is  perhaps  the 
most  convenient  preparation  for  this  purpose;  or  two  grains  of  calomel 
and  half  a  grain  of  opium  may  be  given  every  second  hour,  and  the  inunc- 
tion being  also  used  until  some  slight  effect  be  produced  on  the  gums. 
Another  mode  of  administering  opium,  especially  when  the  stomach  is 
irritable  and  ingesta  are  rejected,  is  by  enemata.  Thirty  or  forty  drops 
of  laudanum  can  be  injected  in  two  or  three  ounces  of  starch  gruel,  and 
such  repeated  according  to  the  exigencies  of  the  case.  If  the  bowels 
should  be  loose  and  the  rectum  inclined  to  expel  its  contents,  a  supposi- 
tory, composed  of  a  couple  of  grains  of  solid  opium  with  a  sufficient  quan- 
tity of  Castile  soap  or  cocoa-nut  butter  to  form  a  conical  mass,  may  be  in- 
troduced joer  amirn,  and  such  from  time  to  time  as  the  physician  may  deem 
desirable.  The  indications  denoting  benefit  having  accrued  from  the  above- 
named  remedies  will  be  mitigation  of  pain,  softer  and  fuller  pulse,  easier 
and  slower  breathing,  more  relaxed  skin,  and  diminution  of  the  abdominal 
distention;  the  face,  too,  will  look  calmer  and  more  natural,  and  the 
patient  probably  give  expression  to  a  more  comfortable  feeling. 

Vesication  is  another  of  our  aids  in  guiding  the  malady  to  a  favorable 
issue.  It  may  be  done  by  means  of  the  ordinary  emplastrum  lytta;  or  by 
the  acetum  cantharidis,  or  the  liquor  epispasticus,  which  are  considered  to 
act  with  more  celerity.  A  large  blister  has  sometimes  appeared  to  be  of 
service,  but  vesicants  should  not  be  applied  at  the  outset  of  the  attack. 
They  are  most  advantageous  when  the  initiatory  symptoms  are  on  the  de- 
cline, when  there  is  not  such  high  arterial  action,  and  when  the  surface 
has  become  cooler.  I  have  seen  them  do  harm  when  applied  too  early. 
The  blistered  part  may  afterwards  be  dressed  with  savin  ointment,  by 
which  means  a  modified  and  beneficial  amount  of  counter-irritation  can  be 
continued. 

When  the  stomach  is  so  irritable  that  scarcely  anything  can  be  re- 
tained, hydrocyanic  acid  in  an  aqueous  mixture,  with  a  little  glycerine 
or  mucilage  added,  is  one  of  the  best  of  remedies.  Effervescing  draughts 
with  the  bicarbonate  of  potash  and  citric  acid  are  sometimes  given,  but 
the  evolution  of  carbonic  acid  gas  by  distending  the  organ  makes  it  con- 
tract upon  itself,  and  the  contents  are  again  pumped  up.  There  is  an- 
other objection  to  their  use;  as  tympanites  always  in  greater  or  less  de- 
gree obtains,  the  distention  of  the  stomach  pushes  up  the  diaphragm  still 
higher,  and  renders  the  respiration  more  difficult;  and,  again,  the  neutral 
salt  which  is  formed,  by  acting  as  an  aperient,  is  liable  to  increase  the 
peristaltic  action  of  the  bowels,  a  result  which  should  be  most  sedulously 
avoided.  When  the  tympany  is  very  considerable  a  fixtid  injection  con- 
sisting of  two  drachms  of  the  tincture  of  assafcetida  in  half  a  pint  or  a 
pint  of  decoction  of  pearl-barley  may  be  administered;  or  an  ounce  of 
the  oil  of  turpentine,  first  being  made  into  an  emulsion  with  the  yolk  of 
^^g  and  then  mixed  with  the  same  quantity  of  barley  decoction  as  before 
mentioned,  can  be  injected.  The  oil  of  turpentine  taken  in  doses  of  ten 
or  fifteen  drops  in  some  emulsion  or  bland  drink,  or  five  or  eight  grains  of 


208  DISEASES    OF   THE   INTESTINES    AND   PERITONEUM. 

the  compound  galbanum  pill,  every  six  or  eight  hours,  are  good  measures 
for  adoption.  When  such  do  not  produce  the  desired  effect,  O'Beirne's 
long  elastic  tube  may  be  introduced  high  up  into  the  bowel  and  there 
allowed  to  remain,  by  which  means  incarcerated  gases  find  a  ready  way 
of  escape  and  much  comfort  is  experienced.  It  is  when  this  condition  of 
tympanites  subsists,  and  gives  great  distress  after  the  inflammation  has 
ceased,  that  such  measures  are  useful.  When  we  do  not  feel  certain  that 
the  inflammatory  action  has  subsided,  and  when  vesication  has  not  re- 
moved the  cuticle,  terebinthinate  embrocations  are  likely  to  be  of  service. 

Constipation  is  another  circumstance  which  in  these  cases  generally 
obtains.  A  right  and  rational  consideration  of  this  matter  is  of  cardinal 
importance,  because  the  very  wrong  notion  is  sometimes  entertained  that 
the  bowels  must  be  moved,  and  under  this  erroneous  reasoning  drastic 
purgatives  have  been  given,  producing,  as  they  were  said  to  do,  much 
mischief.  The  physician  should  bear  in  mind  that  the  constipation  is  nol 
the  cause  but  often  the  effect  of  the  inflammation,  and  that  the  indicated 
mode  of  procedure  is  first  to  subdue  the  inflammatory  action,  when  in  due 
time  restoration  of  function  will  follow.  To  allay  and  mitigate  peristaltic 
action — in  other  words  to  give  rest  to  the  parts  in  a  state  of  lesion  —  is 
to  carry  out  the  same  principle  observed  in  enjoining  the  disuse  of  a  torn 
muscle,  and  in  peremptorily  excluding  light  in  the  treatment  of  an  in- 
flamed eye.  If  it  is  believed  that  there  is  great  accumulation  in  the 
colon,  an  enema  with  olive  oil  and  half  an  ounce  of  the  spirits  of  turpen- 
tine in  decoction  of  barley  may  be  administered  by  means  of  the  O'Beirne 
tube,  and  such  may  be  repeated  if  deemed  necessary;  but  there  is  benefit 
in  frequently  having  recourse  to  this  remedy  in  order  to  keep  up  gentle 
action  of  the  intestines.  To  give  purgatives  by  the  mouih  is  often  to  set 
up  or  augment  the  irritation  in  the  gastric  mucous  membrane,  and  by  in- 
creasing the  peristaltic  action  in  the  bowels  to  aggravate  the  disease. 
The  contents  of  the  intestines  are  often  but  soft  and  pasty  matters,  and 
then  their  presence  can  do  no  harm.  There  is  a  far  greater  liability  to 
error  in  being  too  solicitous  respecting  the  movement  of  the  bowels  than 
in  leaving  them  to  the  efforts  of  nature. 

Diaphoretic  and  diuretic  medicines  are  to  be  used  with  the  foregoing. 
The  acetate  liquor  of  ammonia,  the  jetherial  spirits  of  nitre  with  canfphor 
julep,  form  a  good  mixture,  and  tend  to  keep  the  skin  and  kidneys  in  the 
performance  of  their  functions.  Small  quantities  of  strong  beef-tea  or 
farinaceous  food  are  to  be  given  at  intervals.  Smoler  of  Prague  gives  a 
little  broth  once  or  twice  daily,  and  as  little  drink  as  possible  while  the 
activity  of  the  disease  continues.  Urgent  thirst  may  be  allayed  by  pieces 
of  ice  being  put  into  the  mouth. 

Such,  then,  is  the  line  of  treatment  to  be  pursued  in  the  sthenic  or 
more  flagrant  forms  of  inflammation  of  the  peritoneum,  but  they  are  not 
often  met  with,  and  constitute  exceptions  rather  than  the  rule.  It  would 
be  out  of  place  here  to  enter  upon  that  troubled  question,  the  change  of 
type  in  disease,  but  certain  it  is,  whether  from  agencies  operating  from 
without,  or  from  causes  originating  in  the  organism  itself,  that  depletion 
in  this  disease  is  very  rarely  warrantable  in  the  way  in  which  I  have  de- 
scribed; nevertheless  it  would  be  wrong  to  pass  into  that  extreme  of 
inertness  which  has  of  late  become  but  too  prevalent,  for,  as  I  believe, 
moderate  blood-letting  in  rightly  selected  cases  is  yet,  despite  the  conflio- 
tions  of  controversy  and  the  caprice  of  fashion,  a  valuable  remedy. 

As  observed,  by  far  the  greater  number  of  cases  of  Peritonitis  pre- 
sented to  our  notice  are  of  the  asthenic  type — in  that  adynamic  state  of 


PERITONITIS.  209 

the  system  that  will  not  bear  lowerinj^,  and  in  which  the  general  strength 
should  be  husbanded,  not  destroyed:  for  instance,  in  such  examples  ah 
are  consecutive  upon  or  the  sequels  of  some  foregoing  malady,  when  fol- 
lowing the  eruptive  fevers,  when  metastatic  of  erysipelas,  when  the  com- 
plication of  albuminuria,  when  it  occurs  in  perforation  of  the  bowel  in 
enteric  fever,  in  rhe  bursting  of  a  mesenteric  gland,  in  phthisis  abdominis, 
in  those  occult  blood  changes  which  affect  general  nutrition,  as  in  cancer, 
struma,  and  the  climacteric  period,  or  cirrhosis  and  cardiac  disease,  and 
in  contamination  of  the  fluids,  as  in  pyfemia  and  puerperal  Peritonitis, 
When  we  have  to  treat  it  as  related  to  such  conditions,  our  remedial 
measures  must  be  resolved  upon  with  great  modification.  Opium  in  tlie 
asthenic  form  is  the  chief  agent,  and  Drs.  Graves  and  Stokes  were  among 
the  first  physicians  who  gave  this  drug  very  largely.  An  impression  de- 
cided and  speedy  must  be  made  upon  the  nervous  and  sanguiferous  sys- 
tems, and  in  such  lies  our  main  hope  of  arresting  the  disease.  It  should 
be  given  in  larger  doses,  and  the  effect  kept  up  in  full  and  apparent  man- 
ner, but  not  to  the  induction  of  narcotism.  Two  or  three  grains  may  at 
first  be  prescribed,  and  a  grain  every  four,  three,  or  even  two  hours  after- 
wards. Some  in  very  urgent  cases  give  half  a  grain,  or  even  a  grain, 
every  hour.  But  in  these  perilous  attacks  of  illness  the  patient  should 
be  frequently  visited,  and  the  physician  should  cautiously  watch  the 
effects  of  the  remedy.  Narcotism  will  be  produced  much  sooner  and 
with  a  far  less  dose  in  some  persons  than  in  others.  If  there  be  much 
sickness,  laudanum  injections  should  at  short  intervals  be  administered, 
instead  of  giving  the  drug  by  the  mouth.  In  cases  of  great  prostration 
and  debility,  quinine  and  camphor  may  be  conjointed  with  the  opium. 
In  perforation,  when  the  contents  of  the  bowel  are  liable  to  be  extruded 
into  the  serous  cavity,  and  when  lymph  is  thrown  out,  by  which  means 
the  conservative  attempts  of  nature  are  to  seal  up  the  orifice  and  mend 
the  breach,  to  subdue  and  still  the  action  of  the  part  is  everything.  Mo- 
tion implies  the  pouring  out  of  the  intestinal  matters,  the  removal  of  the 
lymphic  plug — in  other  words,  a  fatal  issue.  To  paralyze  the  bowel  for  a 
time  is  the  aim,  in  order  that  reparation  may  be  favored.  In  these  par- 
ticular cases  I  would  not  give  mercurials  by  the  mouth.  If  they  were  to 
increase  the  flow  of  bile,  and  thus  augment  the  peristaltic  action,  they 
would  do  incalculable  harm.  Inunction,  as  above  recommended,  might 
be  used  until  the  gums  became  slightly  affected.  It  is  far  better  to  de- 
pend upon  opium.  In  perforation  there  is  sometimes  very  great  tolerance 
of  this  drug.  Murchison  has  known  so  large  a  quantity  as  sixty  grains 
to  be  given  in  three  days  with  impunity.  In  traumatic  wounds,  in  the 
operation  for  hernia,  and  in  paracentesis  abdominis,  the  same  kind  of 
treatment  should  be  followed.  Fomentations,  turpentine  stoups,  or  a 
large  poultice  may  at  the  same  time  be  employed.  Subsequently  vesica- 
tion may  be  ordered — and  such  repeated  according  to  circumstances. 

In  that  kind  of  Peritonitis  complicated  with  Bright's  disease,  the  pri- 
mary complaint  should  be  more  regarded  than  the  intercurrent  affection. 
Salivation  is  to  be  carefully  avoided;  diaphoretics,  warm  cataplasms,  rube- 
facients to  the  loins,  warm^  baths,  the  hot-air  bath,  vesicants,  and  nutrients 
are  then  indicated.  When  the  acute  symptoms  have  subsided,  the  com- 
pound jalap  powder  and  Dover's  powder  may  be  given.  When  the  attack 
follows  the  exanthemata,  is  metastatic  of  erysipelas,  or  connected  with 
pyaemia,  mercury  is  inadmissible. 

In  puerpral  peritonitis  the  treatment  is  often  difficult  and  doubtful, 
and  it  should  earnestly  be  borne  in  mind  that  it  is  frequently  associated 
14 


210  DISEASES    OF   TUE    INTESTINES    AND    PERITONEUM. 

■with  or  consecutive  upon  an  altered  or  vitiated  condition  of  the  blood, 
If  the  power  of  the  pulse  warrant  the  lancet,  bleeding,  to  be  of  benefit, 
should  be  done  early.  If  deferred  it  is  likely  to  do  harm.  The  best  au- 
thorities are  emphatic  on  this  point.  Dr.  Ferguson  asserts  that  to  be  ben- 
eficial it  must  be  employed  within  the  first  twenty -four  hours,  and  that 
in  the  second  stage  of  the  disease  it  often  produces  a  rapidly  fatal  result. 
Churchill  is  of  opinion  that  when  the  remedy  is  admissible  the  time  for  its 
beneficial  use  is  very  limited,  and  he  has  seen  no  good  from  its  employ- 
ment after  the  first  twenty-four  hours.  The  first-named  physician  in 
doubtful  cases  gave  ten  grains  of  Dover's  powder,  and  covered  the  abdo- 
men with  a  linseed-meal  poultice,  which  from  its  thickness  would  keep  warm 
for  four  hours.  At  the  expiration  of  that  time,  if  the  symptoms  were 
not  relieved,  ten  grains  more  of  Dover's  powder  and  another  poultice  were 
prescribed.  If  in  other  four  hours  from  this  second  medication  the  mal- 
ady did  not  yield,  he  had  recourse  to  depletion.  Sometimes  when  the 
pain  is  great  and  the  pulse  tolerably  firm,  two  or  three  dozen  leeches  at 
once  applied  and  followed  by  fomentations  give  good  results.  In  the  ma- 
jority of  cases,  measures  will  be  required  which  have  previously  been  de- 
scribed as  suitable  to  the  asthenic  type  of  this  inflammation. 

In  the  Peritonitis  of  children  those  general  principles  are  to  be  aimed 
at  which  have  already  been  given.  It  need  scarcely,  however,  be  more  than 
mentioned  here  that  these  little  patients  always  require  their  maladies  to 
be  managed  with  a  gentle  hand,  and  most  especially  in  the  use  of  deple- 
tion and  opiates.  These  remedies  with  them  are  very  uncertain  in  their 
effects,  and  sometimes  produce  a  far  greater  impress  upon  the  general 
powers  than  calculated  upon  by  the  practitioner.  The  age,  the  history  of 
the  case,  and  the  cardinal  signs  will  be  our  guide,  and  our  measures  should 
be  modified  according  to  the  facts  and  exigencies  of  each  particular  in- 
stance. In  the  sthenic  types,  leeches,  calomel,  and  if  the  age  permit,  care- 
fully regulated  doses  of  opium,  linseed-meal  poultices,  terebinthinate  epi- 
thems,  warm  baths,  and  injections  are  to  be  used.  When  the  affection 
comes  on  as  the  sequel  of  one  or  other  of  the  eruptive  fevers,  if  we  believe 
it  to  be  traceable  to  some  constitutional  malady,  some  depravity  of  the 
organism,  depletion  and  antiphlogistic  means  will  be  unwarrantable;  then 
mercurial  alteratives,  small  opiates,  fomentations,  warm  baths,  and  coun- 
ter-irritation will  be  the  best  measures.  When  the  little  patient  tides 
over  the  more  perilous  days  of  active  disease,  and  the  case  drifts  onwards 
towards  the  more  chronic  condition,  and  when  we  find  that  there  is  effu- 
sion, counter-irritation  and  mild  mercurial  alteratives  should  be  given, 
and  during  convalescence  the  iodide  of  potassium  with  decoction  of  sarsapa- 
rilla,  the  syrup  of  the  iodide  of  iron,  or  quinine  with  the  tincture  of  the 
perchloride  of  iron,  often  produce  excellent  effects.  In  the  strumous  dia- 
thesis cod-liver  oil  may  be  prescribed. 

It  has  in  this  article  been  previously  pointed  out  to  the  reader  that 
Peritonitis  not  seldom  occurs  in  a  partial  manner,  and  as  a  complication 
arising  in  the  course  of  some  foregoing  disease,  as  when  an  antecedent 
malady,  first  instituted  in  some  organ  or  organs  covered  by  the  peritoneum, 
is  at  length  extended  to  it.  For  instance  in  hepatitis,  when  the  convex 
surface  is  the  seat  of  lesion  it  remains  circumscribetl ;  or  the  inflammation 
may  be  extended  through  to  the  pleura,  and  pleuro-pneumonia  result,  as 
in  a  case  which  I  recently  witnessed.  It  is  then  quite  clear  that  our  rem- 
edies should  be  addressed  to  the  viscera  involved,  as  well  as  to  the  serous 
membrane.  In  acute  splenitis  the  turgor  of  that  viscus  should  be  relieved, 
or  it  would  be  vain  to  try  to  mitigate  the  peritoneal  symptoms,  which 


PEKITONITIS.  211 

have  their  origin  in  the  stretched,  tense,  irritated  condition  of  the  capsu- 
lar coverings.  In  the  liver  affection  we  should  as  soon  as  possible  bring 
to  bear  the  influence  of  mercurials;  but  in  diseases  of  the  spleen,  mercu- 
rials are  most  improper  and  would  do  harm.  It  is  incontestable  then  that 
our  diagnosis  must  be  rightly  formed,  or  our  practice  will  be  incorrect. 
In  diarrhoea  and  dysentery,  when  associated  with  an  inflamed  peritoneum 
it  is  needful  at  once  to  control  the  excessive  action  of  the  bowels,  and 
when  such  is  subdued,  the  irritation  extended  to  the  serous  membrane  is 
likely  to  be  subdued  also.  Opiate  enemata,  fomentations,  the  compound 
ipecacuan  powder,  and  counter-irritants  are  the  best  measures.  It  has 
been  remarked  that  the  right  iliac  fossa  is  often  the  seat  of  pain,  the  dis- 
ease being  located  near  the  caecum,  and  it  sometimes  happens  that  the  im- 
paction of  indurated  faeces  has  much  to  do  with  setting  up  the  inflamma- 
tion. Large  bland  enemata,  by  unloading  the  great  bowel,  are  in  such 
cases  of  excellent  service.  When  the  sexual  and  urinary  organs  are  first 
affected  and  Peritonitis  becomes  superadded,  the  primary  disease  should 
be  held  in  view,  and  by  its  mitigation  or  removal  the  consecutive  complaint 
will  be  benefited.  From  all,  then,  which  has  been  said,  it  is  obvious  that 
in  the  treatment  of  every  case  the  successful  issue  will  greatly  depend 
upon  a  clear  and  correct  conception  of  the  nature  of  the  ailment,  and  a 
right  interpretation  of  those  symptoms  which  indicate  the  particular  kind 
of  morbid  changes  which  obtain. 

When  the  more  acute  stage  has  passed  over,  and  those  remedies  suited 
to  the  earlier  period  of  the  attack  have  been  employed,  small  doses  of 
opium  may  still  be  given  in  combination  with  quinine  or  some  of  the  bitter 
infusions.  The  various  preparations  of  iron  are  of  great  value,  and  per- 
haps the  tincture  of  the  perchloride  is  the  best.  It  is  safest  to  defer  as 
long  as  possible  the  use  of  aperients,  and  in  preference  the  gentle  action 
of  the  bowels  should  from  time  to  time  be  promoted  by  bland  enemata. 
When  the  active  state  of  the  affection  has  quite  ended  an  occasional  dose 
of  gray  powder  with  rhubarb  and  the  bicarbonate  of  soda  may  be  given. 
Terebinthinate  and  other  stimulant  embrocations  can  be  applied  to  the 
abdomen  when  there  is  effusion,  and  a  flannel  bandage  round  the  body,  so 
as  to  ensure  moderate  and  well-regulated  pressure,  is  another  mode  of 
favoring  absorption. 

The  diet  and  regimen  during  convalescence  are  of  great  importance. 
At  the  first  soups  and  farinaceous  food  are  to  be  allowed,  and  for  some 
time  solids  should  be  interdicted.  Arrow-root,  tapioca,  the  Indian  corn- 
flour, with  milk,  are  nourishing;  and  veal  or  chicken-broth  with  the 
crumb  of  bread  may  be  given;  and  in  the  course  of  time  beef -tea  with 
toast,  boiled  chicken,  and  pounded  meat  may  be  taken.  When  stimu 
lants  are  needed,  sherry,  weak  brandy  and  water,  claret,  and  bitter  ale 
may  be  allowed.  Flatulent  vegetables  and  acescent  fruits  should  for  some 
time  be  discarded.  An  occasional  warm  bath  to  keep  the  skin  in  proper 
action  is  desirable.  When  the  patient  shall  have  so  far  recovered  as  to 
be  able  to  travel,  change  of  air  will  generally  expedite  his  restoration  to 
health. 


TUBERCLE   OF  THE  PERITONEUM. 

By  John  Syeb  Bbistowe,  M.D.,  F.R.C.P. 


Pathology. — The  deposition  of  tubercular  matter  in  connection  with 
the  peritoneal  membrane  is  of  very  common  occurrence.  For  generally  in 
cases  of  tubercular  ulceration  of  the  bowels,  and  certainly  in  all  those 
cases  in  which  the  ulceration  is  extensive,  gray  granulations  may  be  found 
in  greater  or  less  abundance  studding  those  areas  of  serous  surface  which 
correspond  to  the  areas  of  mucous  ulceration.  But  tubercular  formations 
of  this  kind  seldom  show  any  tendency  to  spread,  and  are  rarely  productive 
of  appreciable  mischief.  They  are  for  the  most  part,  indeed,  purely  local 
phenomena. 

There  are  other  cases,  however,  far  less  common  yet  still  not  infrequent, 
in  which  the  tendency  to  the  deposition  of  tubercle  is  general  throughout 
the  serous  membrane,  and  in  which  ulceration  of  the  bowel  is  evidently 
not  the  starting-point  of  the  peritoneal  affection,  and  indeed  is  often  alto- 
gether absent.  To  these,  which  were  formerly  known  as  mere  varieties 
of  chronic  peritonitis,  the  name  of  Tubercular  Peritonitis  is  now  very 
often  given.  They  are  characterized  not  only  by  the  comparative  severity 
and  extent  of  the  peritoneal  affection,  but  also  by  the  fact  that  the  symp- 
toms of  this  affection  are  usually  well-pronounced,  and  sometimes  indeed 
are  paramount. 

Tubercular  Peritonitis,  like  tuberculosis  generally,  may  occur  at  any 
age,  but  is  probably  most  common  in  early  life.  Out  of  48  cases  extracted 
from  the  records,  for  a  limited  period,  of  St.  Thomas's  Hospital,  3  were 
under  ten,  14  between  ten  and  twenty,  13  between  twenty  and  thirty,  9 
between  thirty  and  forty,  7  between  forty  and  fifty,  and  2  between  fifty 
and  sixty.  But  in  correction  of  these  figures  it  must  be  recollected  that 
children  under  ten  are  admitted  in  small  proportion  into  general  hospitals. 
Out  of  the  same  number  of  cases,  26  were  males,  22  females;  but  222 
tubercular  males  were  admitted  to  127  tubercular  females,  and  proportion- 
ately to  this  number  tubercular  peritonitis  was  more  frequent  in  the  fe- 
male than  in  the  male,  in  the  ratio  of  very  nearly  three  to  two.  In  two 
cases  only  was  the  tubercular  deposit  limited  exclusively  to  the  peritoneum. 
In  all  the  others — namely,  in  46  cases — there  were  tubercular  deposits  in 
other  organs,  and  generally  in  several  other  organs.  In  42  there  was 
tubercle  in  the  lungs;  in  25,  in  the  intestines;  in  25,  in  the  pleurae;  in  20, 
in  the  spleen;  in  14,  in  the  bronchial  glands;  in  11,  in  the  kidneys;  in  10, 
in  the  mesenteric  glands;  in  9,  in  the  liver;  in  8,  in  the  brain;  in  4,  in 
the  uterus  and  Fallopian  tubes;  and  in  1,  in  the  pericardium.     But  taking 


214  DISEASES    OF   THE    INTESTINI-:S    AND   PERITONEUJf. 

into  consideration  the  relative  frequency  with  which  the  several  organs 
just  enumerated  are  the  seats  of  tubercle,  a  very  different  numerical  rela- 
tion than  that  just  given  becomes  apparent  between  tuberculosis  in  them 
severally  and  tuberculosis  of  the  peritoneum.  Thus  tubercular  disease  of 
the  peritoneum  was  present  in  (to  disregard  fractions)  74  per  cent. of  cases 
of  tubercle  of  the  pleura,  in  53  per  cent,  of  cases  of  tubercle  of  the  spleen, 
in  4G  per  cent,  of  cases  of  tubercle  of  the  kidneys,  in  44  per  cent,  of  cases 
of  tubercle  of  the  brain  and  of  the  uterus  and  Fallopian  tubes  respectively, 
in  39  per  cent,  of  cases  of  tubercle  of  the  liver,  in  37  per  cent,  of  cases  of 
tubercle  of  the  bronchial  glands,  in  33  per  cent,  of  cases  of  tubercle  of  the 
pericardium,  in  29  per  cent,  of  cases  of  tubercle  of  the  mesenteric  glands, 
and  in  12  per  cent,  only  of  cases  of  tubercle  of  the  lungs  and  of  tubercle 
of  the  intestines  severally.  It  may  be  worth  while  to  add,  that  out  of  tho 
46  cases  in  which  there  was  tubercular  deposit  in  other  organs  besides  the 
peritoneum,  the  most  serious  lesion  was  in  12  the  tubercular  disease  of  the 
peritoneum;  in  15,  that  in  the  lungs;  in  8,  that  in  the  brain;  in  3,  that 
in  the  pleura;  and  in  1,  that  in  the  intestines. 

Peritoneal  tubercles  present  much  the  same  characters  as  tubercles 
occurring  in  other  parts.  They  are  sometimes  miliary,  or  in  the  form  of 
minute  roundish  spots,  varying  from  mere  points  up  to  the  size  of  a  poppy- 
seed,  and  having  an  opaque  white,  or  grayish  or  yellowish  aspect.  Some- 
times they  form  rounded  or  lobulated  masses,  from  the  size  of  a  tare  up 
to  that  of  a  hazel-nut,  presenting  for  the  most  part  an  opaque  buff  color, 
studded  often  with  black  points  or  patches,  and  exhibiting  a  cheesy  aspect 
and  consistence  which  are  modified  by  the  more  or  less  abundance  of  fi- 
broid material  which  invests  and  permeates  them.  Sometimes  again,  but 
much  more  rarely,  there  are  found,  lying  between  organs  which  are  adhe- 
rent, tubercular  laminas  of  considerable  thickness  and  extent.  Peritoneal 
tubercles  exist  rarely,  if  ever,  independently  of  the  effusion  of  lymph,  and 
indeed  rarely,  if  ever,  are  formed  otherwise  than  in  the  substance  of  such 
adhesions,  although  they  may  subsequently  in  the  progress  of  enlargement 
involve  not  only  the  peritoneum  itself,  but  the  tissues  which  are  subjacent 
to  the  peritoneum.  There  is  probably  no  essential  distinction  between  the 
miliary  form  of  tuberculosis  and  that  in  which  the  tubercles  form  masses 
of  larger  size:  the  former,  however,  are  most  frequently  found  in  cases  of 
acute  progress,  the  latter  in  cases  which  are  chronic;  the  former,  more- 
over, are  generally  discovered  thickly-set  and  innumerable,  the  latter  in 
comparatively  small  numbers.  In  cases  of  miliary  tuberculosis  indeed, 
the  peritoneal  surface  is  mostly  found  covered  with  a  layer,  of  various 
thickness,  of  grayish,  transparent,  adherent  and  toughish  lymph,  which 
not  only  invests  the  abdominal  organs,  but  renders  them  more  or  less  ad- 
herent to  one  another.  And  in  the  substance  of  this  lymph  the  tubercles 
arc  disseminated  as  opaque  grains,  which  may  be  separated  with  the  lymph 
from  the  subjacent  peritoneal  surface.  This  condition  may  be  general,  or 
it  may  be  limited  to  certain  regions,  and  not  infrequently  when  thus  lim- 
ited the  parts  affected  are  studded  with  filaments  of  lymph,  in  which  mili- 
ary tubercles  may  be  recognized.  In  the  other  form  of  the  disease,  the 
peritoneal  surface  is  covered  with  lymph  which  has  assumed  the  form  of 
connective  tissue,  and  the  adhesions  between  organs  are  formed  of  tough 
fibrous  bands.  And  it  is  in  this  tissue,  and  especially  among  these  bands 
(sometimes  forming  the  centre  of  a  kind  of  knot,  sometimes  forming  flat- 
tened masses  between  closely  united  surfaces),  that  the  large  masses  of 
tubercle  are  for  the  most  part  found.  It  is  this  form  of  tubercle  which 
oceasionally  invades  the  intestinal  walls,  and  leads  to  perforation  of  the 


TUBEROTiE   OF   THE   PERITOTJrEUM.  215 

bowel  from  without.  In  association  with  the  deposition  of  peritonea) 
tubercle,  the  various  accompanin>ents  and  sequelae  of  common  inflamma- 
tion manifest  themselves  generally  in  a  greater  or  less  degree.  Thus,  there 
is  often  patchy  and  streaky  redness,  often  fibrinous  effusion  which  is  not 
visibly  tubercular,  and  often  effusion  of  serum ;  sometimes  there  is  suppu- 
ration, and  sometimes  again  haemorrhage  into  the  peritoneum.  The  most 
important  of  these,  from  its  frequency,  is  undoubtedly  the  effusion  of 
serum.  Indeed  tubercular  disease  of  the  peritoneum  is  a  common  cause 
of  ascites.  It  is  probable  that  most  cases  in  which  tubercle  exists  on  the 
peritoneal  surface  prove  fatal  sooner  or  later,  either  from  the  direct  effects 
of  the  peritoneal  disease  or  from  the  effects  of  tuberculosis  in  other  organs. 
Yet  there  can  be  no  reasonable  doubt  that  recovery  sometimes  takes  place. 
For  not  only  does  our  knowledge  of  the  progress  of  tubercle  in  the  lungs 
justify  us  in  this  inference,  but  we  not  infrequently  meet  with  cases  of 
recovery  from  symptoms  which  we  have  the  strongest  reasons  to  regard 
as  dependent  on  tubercular  peritonitis,  and  still  more,  we  occasionally  de- 
tect in  the  abdomens  of  persons  dead  of  other  diseases  signs  of  old  peri- 
tonitis, together  with  the  presence  of  earthy  nodules  such  as  result  from 
the  drying  up  of  tubercle. 

Symptoms. — The  symptoms  which  attend  the  progress  of  peritoneal 
tuberculosis  present  much  variety,  and  are  often  vague  and  indefinite. 
Often,  indeed,  and  not  only  in  those  cases  in  which  the  peritoneal  affec- 
tion is  slight,  or  in  those  in  which  it  is  as  it  were  overshadowed  by  the 
preponderance  of  disease  in  other  parts,  but  in  those  cases  even  in  which 
it  is  the  predominant  or  sole  affection,  they  fail  to  indicate  clearly  the  peri- 
toneum as  the  seat  of  any  disease.  Further,  they  are  so  generally  compli- 
cated with  the  symptoms  which  are  due  to  co-existing  tubercular  disease 
in  other  organs,  especially  in  the  lungs,  pleurae,  and  intestines,  that  it  is 
impossible  altogether  to  dissociate  them  from  these  latter. 

Most  cases,  however,  of  tubercular  peritonitis,  in  which  there  are  obvi- 
ous indications  of  abdominal  disease,  may  be  arranged,  somewhat  roughly 
perhaps,  in  two  classes:  the  first,  the  acute  class,  in  which  the  symptoms 
bear  a  considerable  resemblance  to  those  of  enteric  or  of  so-called  "  remit- 
tent" fever;  the  second,  the  chronic  class,  in  which  the  symptoms  corre- 
spond for  the  most  part  with  those  of  "  chronic  peritonitis."  In  the  acute 
form  of  the  disease,  the  patient  sometimes  in  the  midst  of  perfect  health, 
more  often  however  after  some  indefinite  period  of  languor  and  loss  of  flesh 
and  strength,  begins  to  manifest  febrile  symptoms  attended  with  remis- 
sions and  indicated  by  heat  and  dryness  of  surface  with  quickened  pulse, 
pains  in  the  limbs  and  loins  and  head,  diminution  of  the  secretions,  and 
perhaps  drowsiness.  At  the  same  time  the  abdomen  probably  becomes 
somewhat  hard  and  tumid  and  tender,  and  the  patient  complains  of  more 
or  less  pain  in  it.  Generally  also  there  is  some  disturbance  of  the  diges- 
tive functions,  dryness  or  furring  of  the  tongue,  thirst,  loss  of  appetite, 
and  nausea  or  sickness,  with  probably  constipation  or  diarrhoea,  or  an 
alternation  of  these  conditions.  And  with  no  material  change  in  these 
symptoms,  perhaps,  beyond  that  which  is  due  to  gradually  increasing  de- 
bility and  emaciation  and  the  gradual  supervention  of  what  are  ordinarily 
known  as  "typhoid  symptoms,"  the  patient  gradually  sinks,  and  at  the 
end  of  a  few  weeks  dies.  The  distinctions  between  acute  abdominal  tuber- 
culosis and  enteric  fever  consist,  as  regards  the  former  disease,  partly  in 
the  absence  of  rash,  the  less  constant  disturbance  of  the  bowels,  the  non- 
limitation  of  tenderness  to  the  caecal  region,  and  the  less  definite  duration 
of  the  disease,  and  partly  in  the  occasional  presence  of  characteristic  com- 


216         DISEASES    OF   THE    INTESTINES   AND    PERITONEUM. 

plications,  among  which  may  be  enumerated  tubercle  in  the  brain,  pulmO" 
nary  phthisis,  renal  disease  with  albuminuria,  and  the  accumulation  of 
ascitic  fluid.  It  may  be  remarked,  however,  that  even  in  spite  of  care  the 
cerebral  symptoms  arising  from  tubercle  in  the  brain  may  be  mistaken  in 
some  cases  for  the  delirium  of  enteric  fever,  and  the  symptoms  of  pulmo- 
nary tuberculosis  may  pass  for  those  of  the  pulmonary  affections  which  so 
commonly  ensue  in  that  fever;  and  further,  that  the  liability  in  both  cases 
to  intestinal  perforation  and  acute  peritonitic  symptoms  furnishes  an  ele- 
ment of  serious  difficulty  in  reference  to  diagnosis.  In  the  chronic  variety 
of  peritoneal  tuberculosis,  the  disease  sometimes  commences  with  more  or 
less  typical  symptoms  of  acute  peritonitis,  sometimes  creeps  on  with  the 
utmost  insidiousness;  but  in  both  cases  (in  the  one  after  the  disease  has 
become  fully  established,  in  the  other  after  the  acute  initial  symptoms 
have  subsided)  the  symptoms  gradually  become  more  or  less  identical  with 
those  which  have  been  described  elsewhere  as  indicative  of  chronic  peri- 
tonitis: symptoms  which,  with  many  variations  and  remissions  and  ex- 
acerbations, may  continue  for  a  month  or  longer,  and  upon  which  in  most 
cases  sooner  or  later  ascites  supervenes.  It  must  not  be  forgotten  that  in 
the  chronic,  as  well  as  in  the  acute  affection,  deposition  of  tubercles  in 
other  organs  is  apt  to  take  place,  and  that  in  its  course  the  presence  of 
tubercles  in  the  brain,  lungs,  bowels,  or  elsewhere,  may  produce  symptoms 
which  may  lead  us  or  mislead  us  in  our  diagnosis;  and  that  in  this  case, 
even  more  than  in  the  other,  there  is  liability  to  tubercular  perforation  of 
the  bowel,  and  to  lardaceous  or  other  degenerative  diseases  of  important 
organs,  especially  of  the  liver  and  the  kidneys. 

As  examples  of  some  of  the  many  anomalous  cases  which  do  not  by 
their  symptoms  fall  very  obviously  under  either  of  the  above  categories, 
I  may  here  briefly  quote  two  cases.  A  girl  about  twenty  had  been  ailing 
for  some  twelve  or  fifteen  months.  She  had  been  getting  weak  and  thin, 
and  had  been  suffering  from  attacks  of  severe  sickness,  coming  on  with 
some  regularity  every  three  or  four  days.  The  sickness  was  rem.arkable 
from  the  facts  that  during  the  three  or  four  hours  for  which  it  lasted  she 
would  bring  up  as  much  as  a  couple  of  wash-hand-basinfuls  of  nearly  clear 
fluid,  that  it  was  apparently  independent  of  the  ingestion  of  food,  and 
that  between  whiles  she  had  no  symptoms  of  indigestion  and  had  a  good 
appetite.  There  was,  further,  no  affection  of  the  bowels,  and  no  distinct 
abdominal  enlargement  or  tenderness.  These  symptoms  continued  while 
she  was  under  my  care;  but  shortly  after  she  came  under  mj^  care,  and 
then  for  the  first  time,  a  cough  came  on,  consolidation  was  discovered 
under  the  left  clavicle,  and  from  that  time  pulmonary  consumption  made 
rapid  progress.  Her  death,  which  was  mainly  caused  by  the  pulmonary 
disease,  occurred  about  three  months  after  I  first  saw  her;  and  at  the 
post-mortem  examination  there  was  found,  in  addition  to  extensive  tuber- 
cular disease  of  the  lungs,  very  extensive  peritoneal  tuberculosis.  The 
stomach  and  bowels  were  healthy. — A  young  gentleman  of  two  or  three 
and  twenty,  who  was  at  the  time  resident  at  Port  Natal,  became  without 
any  apparent  cause  subject  to  attacks  of  intense  colic,  in  which  he  was 
compelled  by  the  severity  of  the  pain  to  throw  himself  down  and  writhe. 
He  came  over  to  England  in  consequence  of  the  persistence  of  this  affec- 
tion. The  attacks  of  pain  still  continued,  coming  on  sometimes  two  or 
three  times  a  day;  but  there  was  also  some  irregularity  of  the  bowels. 
His  illness  lasted  for  about  a  couple  of  years,  and  he  died  then  from  ema- 
ciation and  exhaustion.  There  was  more  or  less  general  tuberculosis  dis- 
covered after  death;   but  the  chief  deposit  was  in  connection  with  the 


TUBERCLE  OF  THE  PERITONEUM.  217 

peritoneum.  Occasionally  the  chief  symptoms  due  to  the  presence  of 
peritoneal  tubercle  are  great  obstinacy  of  the  bowels,  with  gradually  in- 
creasing emaciation  and  debility;  and  occasionally  there  is  complete  and 
insuperable  obstruction.  In  some  cases,  ascites  is  the  earliest  prominent 
symptom,  and  it  may  continue  the  most  prominent  symptom,  and  then 
prove  (as  ascites  from  other  causes  often  proves)  the  chief  agent  in  cau»> 
ing  death. 


CARCINOMA  OF  THE  PERITONEUM. 

By  John  Syeb  Bkistowe,  M.D.,  F.R.C.P. 


Pathology. — Carcinoma  of  the  Peritoneum,  using  the  term  in  its 
widest  sense,  is  not  infrequently  met  with.  Taking  for  comparison  the 
same  period  which  furnished,  from  the  medical  wards  of  St.  Thomas's 
Hospital,  349  cases  of  tuberculosis  of  which  49  presented  peritoneal  com- 
plications, there  were  99  cases  of  cancer,  in  22  of  which  the  peritoneal 
membrane  was  affected.  From  these  figures  it  would  appear  that  while 
cancer  of  the  peritoneum  is  less  than  half  as  common  as  tuberculosis  of 
that  membrane,  it  is  considerably  more  common  in  reference  to  all  cases 
of  cancer  than  tubercle  of  the  peritoneum  is  to  all  cases  of  tuberculosis. 

There  is  probably  no  great  difference  in  the  liability  of  the  two  sexes 
to  this  disease;  but  there  is  no  doubt,  I  think,  that  it  is  relatively  less 
frequent  in  early  life  than  tuberculosis.  Of  the  22  cases  alluded  to  above, 
none  occurred  under  twenty,  3  occurred  between  twenty  and  thirty,  4 
between  thirty  and  forty,  5  between  forty  and  fifty,  5  between  fifty  and 
sixty,  and  5  between  sixty  and  seventy.  In  2  cases  the  disease  was  ap- 
parently limited  to  the  peritoneum,  or  had  at  most  invaded  the  surface  of 
organs  invested  with  the  peritoneum.  It  was  associated  in  11  cases  with 
cancer  of  the  stomach,  in  10  with  cancer  of  the  liver,  in  9  with  cancer  of 
the  pleurae,  in  7  with  cancer  of  the  lungs,  in  6  with  cancer  of  the  mesen- 
teric glands,  and  in  3  severally  with  cancer  of  the  bowels,  kidneys,  and 
ovaries.  More  than  half  the  cases,  however,  of  cancer  of  the  bowels  were 
combined  with  peritoneal  cancer;  rather  less  than  half  the  cases  of  cancer 
of  the  pleurag  and  stomach  respectively  were  associated  with  it;  and 
about  a  fourth  of  all  cases  of  cancer  of  the  liver,  mesenteric  glands,  kid- 
neys, ovaries,  and  lungs  respectively  presented  the  same  complication.  In 
7  cases  the  peritoneal  cancer  was  the  predominant  disease,  in  10  cancer  of 
the  stomach,  in  1  cancer  of  the  liver,  and  in  1  cancer  of  the  mesenteric 
glands.  It  may  be  added  here,  that  in  speaking  of  peritoneal  cancer, 
those  cases  have  been  excluded  in  which  that  portion  of  peritoneum 
covering  a  cancerous  organ  has  alone  presented  indications  of  cancerous 
growth. 

Carcinoma  of  the  Peritoneum  presents  most  of  the  varieties  which 
carcinoma  presents  in  other  parts  of  the  body;  namely,  scirrhus,  encepha- 
loid  (with  its  sub-variety  melanotic  cancer),  and  colloid.  Scirrhus  always 
commences  in  the  form  of  flat,  round,  lenticular,  hard,  white  spots,  meas- 
uring perhaps  on  the  average  a  line  in  diameter,  which  occupy  the  sub- 
stance of  the  serous  membrane,  and  though  distinctly  projecting  from  the 
surface,  yet  rather  tend  to  invade  and  involve  the  sub-serous  tissue.  These 
are  in  the  first  instance  scattered  thinly  or  irregularly,  but  soon  become 
aggregated  in  parts  or  generally,  and  then  coalesce  so  as  to  form  patches 


220         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

of  various  extent.  The  patches  thus  formed  may  be  perfectly  smooth  on 
the  surface,  or  may  still  present  there  traces  of  the  mode  in  which  they 
were  originally  formed;  they  rarely,  however,  form  outgrowths,  and  pretty 
rarely  invade  subjacent  organs;  rarely,  too,  over  the  general  peritoneal 
surface  do  they  become  more  than  a  line  or  two  thick,  except  when  they 
involve  duplicatures  or  processes  of  peritoneum.  The  latter  involvement 
is  indeed  somewhat  characteristic  of  the  disease.  The  appendices  cpipl6ica3 
become  converted  into  small  hard  masses,  in  which  the  cancerous  deposit 
and  the  fat  and  other  normal  tissues  become  intermixed;  the  mesenteric 
and  other  like  duplicatures  become  often  similarly  affected;  and  the  great 
omentum,  from  the  same  cause,  becomes  contracted  into  a  thick  band, 
stretching  transversely  across  the  abdomen  in  the  course  of  the  transverse 
colon.  Scirrhous  cancer,  in  fact,  as  has  long  been  recognized,  tends  rather 
to  cause  contraction  of  parts  than  outgrowths:  and  for  this  same  reason 
has  a  special  tendency  not  only  to  cause  the  contractions  of  loose  tissues 
already  adverted  to,  but  to  lead  to  obstruction  of  tubular  organs,  especially 
of  the  stomach,  intestines  and  larger  bile-ducts.  Encephaloid  also  in  its  early 
stage  affects  the  substance  of  the  peritoneum,  and  forms  discrete  nodular 
outgrowths,  which  are  small  and  rounded,  and  differ  from  those  of  scirrhus 
not  only  in  their  greater  softness,  but  also  in  their  greater  prominence.  These 
are  often  indeed  hemispherical,  or  even  spherical  or  pyriform  and  peduncu- 
lated. In  its  further  progress  encephaloid  presents  great  varieties.  In  some 
cases  it  seems,  like  scirrhus,  to  invade  more  particularly  the  substance  of 
the  peritoneal  folds,  and  to  involve  also  subjacent  organs;  and  under  such 
circumstances  we  find  sometimes  the  mesentery  converted  into  a  thick, 
plicated,  cancerous  mass,  with  the  cancerous  growth  extending  from  the 
mesenteric  attachment  over  the  surface  of  the  intestines;  or  we  find  the 
greater  or  lesser  omentum  or  the  sub-peritoneal  tissue  of  other  regions  af- 
fected in  like  manner,  and  forming  a  more  or  less  distinct  tumor.  In 
other  cases  it  tends  rather  to  form  outgrowths  which  are  sometimes  small 
and  clustered,  sometimes  more  or  less  distinct  from  one  another  and 
rounded  and  massive.  In  the  former  instance  the  whole  peritoneal  surface 
may  be  found  beset  with  small  lobulated  or  bunch-of-currant-like  ex- 
crescences, and  the  great  omentum  may  be  converted  into  a  huge  loose 
mass  of  such  bodies.  In  the  latter  instance  the  tumors,  though  more  or 
less  abundant,  are  isolated,  and  while  many  probably  are  small,  others 
form  rounded  solid  masses  which  may  attain  the  size  of  a  child's  head. 
So  far  as  I  know,  melanotic  cancer  always  manifests  itself  in  this  latter 
condition.  Colloid  disease  in  its  early  stage  appears  for  the  most  part  in 
the  form  of  groups  of  vesicles  which  vary  in  fineness  and  have  a  close 
prinid  facie  resemblance  to  patches  of  eczema  or  herpes,  or  (if  the  fibroid 
elemeiit  be  abundant)  in  the  form  of  slightly  granular  or  delicately-reticu- 
lated patches.  Later  on,  the  vesicle-like  bodies  are  often  as  large  as  a 
millet-seed  or  tare.  The  patches  often  become  more  or  less  elevated  above 
the  level  of  the  surrounding  surface,  and  spread  sometimes  in  tortuous 
and  anastomosing  lines  as  though  taking  the  course  of  the  lymphatic  ves- 
sels, sometimes  by  forming  scattered,  isolated,  somewhat  pedunculated 
growths.  This  disease,  like  scirrhus  and  encephaloid,  tends  in  various 
degrees  both  to  involve  subjacent  organs  and  to  diffuse  itself  over  the 
peritoneal  surface.  It  always  involves  the  sub-peritoneal  tissue,  which 
may  attain  in  consequence  very  considerable  thickness;  and  it  extends 
thence  most  frequently  to  the  muscular  and  mucous  coats  of  the  stomach 
and  intestines,  less  frequently  to  the  substance  of  the  mesenteric  glands, 
pancreas,  liver,  s])leen,   or  other  viscera.     In   the  most  extreme  cases  of 


CARCINOMA    OF   TIIE   PERITONEUM.  221 

the  disease,  nearly  the  whole  of  the  peritoneum  is  affected ;  this  membrane 
is  then  irregularly  thickened,  with  lumpy  excrescences  here  and  there; 
the  various  duplicatures  become  especially  hypertrophied;  and  the  great 
omentum  is  sometimes  converted  into  a  huge  lobulated  mass,  or  is  con- 
tracted, as  it  generally  is  in  scirrhus,  into  a  thick  irregular  transverse 
band.  In  all  these  cases  the  adventitious  growth  retains  its  original  more 
or  less  distinctly  vesicular  if  not  gelatinous  character;  and  generally, 
sooner  or  latter,  from  erosion  of  its  surface,  the  glairy  fluid  contained  in 
its  substance  is  discharged  in  some  abundance  into  the  cavity  of  the  abdo- 
men. 

Other  varieties  of  cancer,  such  for  example  as  osteoid  cancer,  are  prob- 
ably always  secondary,  and  are  of  such  extremely  rare  occurrence  as  to  be 
of  no  practical  importance. 

All  forms  of  abdominal  cancer  are  liable  in  a  greater  or  less  degree  to 
various  complications.  Among  which  may  be  enumerated:  peritoneal  in- 
flammation, with  the  effusion  of  lymph  or  pus,  or  the  escape  of  blood; 
ascites;  obstructions  of  stomach  or  bowels;  involvement  of  the  viscera, 
audi  as  the  liver  or  kidneys,  or  their  excretory  ducts;  and  perforations  of 
the  stomach  and  intestines  or  other  hollow  organs. 

Symptoms. — The  symptoms  of  peritoneal  cancer  are  necessarily  very 
various  and  often  quite  as  easy  to  be  misunderstood  as  those  of  peritoneal 
tubercle.  Febrile  symptoms,  varying  in  intensity  and  liable  to  remissions, 
gradually  increasing  debility  and  emaciation,  more  or  less  uneasiness  or 
tenderness  or  pain  in  the  abdomen,  with  hardness  and  enlargement  of  the 
same  part,  disturbance  of  the  functions  of  the  alimentary  canal  indicated 
by  dry  and  glazed  or  coated  tongue,  thirst,  loss  of  appetite,  with  perhaps 
nausea  and  sickness,  and  by  constipation  or  diarrhoea  or  alternations  of 
both,  are  symptoms  which  are  common  alike  to  cancer  and  to  tubercle  and 
to  mere  chronic  inflammation  of  the  peritoneum.  It  is  important,  how- 
ever, to  bear  in  mind  that  obstinate  constipation  is  a  very  frequent  accom- 
paniment of  this  disease,  and  that  much  more  frequently  than  in  either 
turberculosis  or  inflammation,  death  results  from  complete  obstruction ; 
also,  that  in  a  very  large  proportion  of  cases  the  stomach  is  involved  in  a 
greater  or  less  degree,  and  that  consequently  the  usual  symptoms  of 
stomach-cancer  are  very  liable  to  be  associated  with  those  of  the  peri- 
toneal affection;  further,  that  in  nearly  half  the  cases  there  is  cancer  of 
the  liver,  not  infrequently  involving  that  organ  through  the  gastro-hepa- 
tic  omentum  and  Glisson's  capsule,  and  that  therefore  obstruction  of  the 
bile-ducts  and  jaundice  are  of  common  occurrence;  and  lastly,  that  in  the 
female  there  is  frequent  co-existence  of  ovarian  and  peritoneal  cancer. 
The  most  important  points,  however,  to  which  we  must  look  for  the  for- 
mation of  a  correct  diagnosis  are,  first,  the  presence  of  a  growing  tumor 
or  tumors  in  the  abdomen,  and,  second,  the  presence  of  similar  disease  in 
other  parts.  It  need  scarcely  be  said  that  cancerous  tumors  present  all 
varieties  of  character;  that  they  may  occur  in  any  region  of  the  abdomen; 
that  they  may  be  movable  or  fixed;  that  they  may  vary  widely  in  size 
and  shape;  that  they  may  be  hard  and  resisting, or  soft  and  almost  yield- 
ing a  sense  of  fluctuation;  and  that,  especially  when  they  are  developed 
in  the  neighborhood  of  the  coeliac  axis  and  superior  mesenteric  artery, 
they  may  pulsate  as  violently  as  many  aneurisms  do;  and  that  hence  not- 
withstanding the  important  aid  which  their  presence  furnishes,  they  may 
be,  and  are  not  infrequently,  confounded,  at  some  stage  at  least  of  their 
progress,  with  circumscribed  abscesses,  or  hydatid  tumors,  or  floating  kid- 
neys, or  even  aneurisms.     But  in  some  cases  where,  although  the  cancer- 


222         DISEASES   OF  THE  INTESTINES   AND   PERITONEUM. 

ous  disease  is  very  extensive,  the  individual  tumors  are  small,  the  presence 
of  the  peritoneal  outgrowths  may  fail  of  detection,  even  when  very  care* 
ful  examination  has  been  made;  and  necessarily  this  difficulty  of  detection 
is  always  greatly  increased  when  ascitic  fluid  is  present.  It  is  worth 
while  to  draw  attention  to  the  fact,  that  not  infrequently  when  no  other 
signs  of  tumor  are  distinguishable,  the  presence  of  the  thickened  and  con- 
tracted great  omentum,  which  has  been  shown  to  be  common  in  scirrhus 
and  in  colloid  disease,  may  be  recognized  as  a  more  or  less  irregular  trans- 
verse bar  extending  horizontally  from  under  the  margins  of  the  left  ribs 
across  the  upper  part  of  the  umbilical  region  to  the  neighborhood  of  the 
umbilicus,  and  that  this  furnishes  a  valuable  diagnostic  sign. 

It  is  impossible  to  lay  down  any  rules  with  regard  to  the  detection  of 
concurrent  cancerous  disease  in  other  organs;  but  it  is  obvious  that  in  all 
cases  in  which  there  is  any  ground  to  suspect  that  a  patient  may  be  suffer- 
ing from  internal  cancer,  a  careful  investigation  of  all  superficial  and 
other  easily  accessible  parts  should  be  made;  for  not  infrequently  there 
may  be  found  associated  with  the  internal  cancer,  coming  on  before  it,  or 
appearing  at  a  later  period,  cancerous  nodules  in  the  subcutaneous  cellu- 
lar tissue,  cancerous  growths  of  periosteum,  or  bone,  or  cancer  affecting 
the  uterus,  mamma,  or  testis.  Nor  must  it  be  forgotten  that  cancer  of 
the  pleurfE,  lungs,  and  mediastinum,  cancer  of  the  brain,  and  cancer  of  the 
kidneys,  are  all  with  different  degrees  of  frequency  apt  to  be  associated 
with  cancer  of  the  peritoneum. 

Ti'eatment  of  Abdominal  Tubercle  and  Carcinoma. — There  are  stages 
in  many  varieties  of  the  diseases  coming  under  the  above  heads,  when,  as 
has  been  shown,  they  may  be  readily  mistaken  for  other  affections  of  a  less 
grave  character  than  themselves;  and  when  therefore  it  may  be  judicious 
to  adopt  the  treatment,  whatever  it  may  be,  which  may  seem  most  suitable 
for  the  more  curable  malady.  But,  assuming  the  fact  of  the  presence  of 
tubercle  or  of  cancer  to  be  known,  the  principles  of  treatment  become  ex- 
ceedingly simple:  they  are,  to  relieve  pain  and  discomfort  by  ministering 
to  those  symptoms  which  most  distress  the  patient,  and  to  support  his 
strength  by  the  judicious  exhibition  of  food  and  stimulus,  and  by  the  use 
of  medicines  having  a  similar  tendency.  Abdominal  pains  may  need  to 
be  relieved  by  the  application  of  counter-irritants,  or  fomentations,  or  even 
leeches.  Sleepless  weariness  and  pain  may  require  to  be  overcome  oy  the 
use  of  opiates  or  other  forms  of  sedative  or  narcotic  medicines;  and  indeed, 
in  the  progress  of  cancer  especially,  these  remedies  are  often  the  only  ones 
that  can  be  employed,  and  may  have  to  be  given  constantly  and  in  large 
doses.  Nausea,  sickness,  diarrhoea,  obstruction  of  the  bowels,  will  each 
in  various  cases  call  for  treatment,  but  nothing  special  need  be  said  in 
reference  to  them.  That  tonics,  food,  and  stimulants,  of  such  kind  and 
in  such  quantities  and  at  such  intervals  as  the  condition  of  the  patient 
renders  admissible  should  be  persisted  in  is  obvious,  not  only  because  the 
maintenance  of  life  up  to  the  extreme  limits  which  the  progress  of  the 
diseases  admits  of  depends  thereon  —  and  it  is  our  recognized  duty  as 
physicians  to  sustain  life  even  when  it  is  a  hopeless  burden — but  because 
(to  say  nothing  of  the  chance  there  may  be  of  our  diagnosis  being  in  some 
cases  erroneous)  there  may  be,  at  least  in  the  case  of  tubercular  disease,  a 
prospect,  however  remote,  of  ultimate  recovery. 


AFFECTIONS  OF  THE  ABDOMINAL  LYMPHATIC 

GLANDS. 

By  John  Syer  Bristowe,  M.D.,  F.R.C.P. 


The  lymphatic  and  lacteal  glands  of  the  abdomen  are  frequently  the 
seat  of  disease;  sometimes  they  become  inflamed,  sometimes  hypertro- 
phied,  sometimes  tubercular,  and  sometimes  the  seat  of  the  various  forms 
of  cancerous  growth  and  of  degenerative  changes. 

In  inflammation  they  become  enlarged,  congested,  softened,  and  ten- 
der, and  sometimes  undergo  suppuration,  and  may  then  discharge  their 
contents  by  various  routes,  and  even  by  rupture  into  the  peritoneum. 
When  the  inflammation  subsides  they  may  according  to  circumstances 
recover  their  healthy  state,  or  remain  enlarged,  or  become  atrophied  and 
indurated.  The  symptoms  indicative  of  their  inflammation  are  more 
or  less  pain  and  tenderness  in  the  situation  of  the  affected  glands, 
with  perhaps  hardness  or  distinct  tumor,  and  more  or  less  violent  inflam- 
matory fever.  Inflammation  of  the  abdominal  glands  is  probably  of  very 
common  occurrence  as  secondary  to  inflammation  or  ulceration  of  the 
various  organs  with  which  they  are  in  connection,  but  we  are  chiefly 
acquainted  with  inflammation  of  the  mesenteric  glands  in  enteric  fever, 
and  in  dysentery,  and  of  the  lumbar  glands  and  those  about  the  brim  of 
the  pelvis  in  connection  with  inflammatory  affections  of  the  genito-urinary 
organs. 

Hypertrophy  of  the  glands  is  not  very  easy  to  separate  from  tubercu- 
lar disease  of  the  glands  on  the  one  hand,  and  from  some  forms  of  malig- 
nant disease  on  the  other.  It  is  indicated  by  a  more  or  less  gradual 
increase  in  their  size,  attended  with  a  more  or  less  fleshy  consistence,  and 
a  color  varying  between  a  dull  white  or  buff,  and  a  reddish  fleshy  hue. 
It  is  an  affection  rarely  limited  to  the  glands  of  a  particular  part;  and 
generally,  therefore,  when  the  abdominal  glands  are  hypertrophied,  the 
lymphatics  of  other  parts  of  the  body  are  liypertrophied  also.  The  symp- 
toms which  attend  this  affection  are  rarely  connected  specially  with  the 
abdomen;  excepting  in  so  far  as  there  may  be  a  tumor  there,  and  more 
or  less  impairment  of  nutrition ;  they  are  for  the  most  part  those  of  grad- 
ually increasing  anaemia,  and  a  form  of  cachexia,  in  which  sometimes 
there  is  a  remarkable  increase  of  white  corpuscles  in  the  blood  (Leucocy- 
thaimia). 

Tubercular  deposits,  in  the  mesenteric  glands  especially,  are  not 
uncommonly  associated  with  similar  deposits  in  the  peritoneum  and  intes- 
tines; and  they  generally  form  well-defined  cheesy  lumps  embedded  in 
enlarged  and  more  or  less  congested  gland  substance.  Not  very  infre- 
quently such  deposits  take  place  in  glands  which  have  previously  under- 
gone hypertrophy,  and  to  such  an  extent  sometimes  that  whole  glands 


224         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

become  caseous.  Tubercular  glands  sometimes  soften  or  suppurate  and  form 
vomicos;  and  very  frequently  indeed  dry  up  and  contract  and  become  con- 
verted into  inert  cretaceous  masses.  This  condition  of  glands  is  probably 
attended  with  no  symptoms  distinguishable  from  the  symptoms  due  to  the 
associated  tubercular  affection  of  other  abdominal  organs  which  is  gener- 
ally present. 

Cancerous  disease  of  the  various  abdominal  glands  is  common  in  all 
its  varieties.  It  is  sometimes  primary  (in  which  case  it  is  probably  gen- 
erally if  not  always  some  variety  of  what  Virchow  terms  lymphoma). 
It  is  more  frequently  secondary  to  cancer  of  other  parts;  and  then,  for 
the  most  part,  the  glands  chiefly  affected  are  those  which  are  in  relation 
with  the  organ  primarily  affected.  Thus,  in  cancer  of  the  testis  the  lum- 
bar glands  become  cancerous;  in  cancer  affecting  the  remaining  genito- 
urinary organs,  and  other  organs  situated  in  the  pelvis,  the  glands  which 
become  specially  implicated  are  those  in  the  pelvis,  and  about  its  brim; 
in  cancer  of  the  bowels,  the  mesenteric  glands  chiefly  suffer;  and  in  can- 
cer of  the  stomach,  kidneys,  and  neighboring  parts,  the  retro-peritoneal 
glands  of  the  upper  part  of  the  abdomen.  Cancerous  glandular  tumors 
sometimes  attain  an  enormous  size;  and  it  is  not  infrequently  by  their 
growth  and  disintegration  that  perforation  or  obstruction  of  viscera,  and 
other  serious  complications,  which  have  been  elsewhere  sufficiently  de- 
scribed, are  produced.  It  is  diflacult,  and  would  be  useless,  to  discuss 
the  symptoms  and  effects  of  such  tumors  apart  from  those  of  cancer  of 
the  peritoneum  and  other  abdominal  organs,  which  have  been  already 
fully  considered. 

In  addition  to  the  degenerations  which  follow  upon  inflammation,  and 
upon  the  deposition  of  tubercle,  it  may  be  stated  that  in  extreme  cases  of 
lardaceous  disease,  the  abdominal  lacteal  and  lymphatic  glands  may  share 
with  other  parts  in  this  form  of  degeneration. 


ASCITES. 

By  John  Sybb  Bbistowe,  M.D.,  F.R.C.P. 


Pathology. — The  accumulation  of  fluid  of  a  more  or  less  serous  char- 
acter within  the  peritoneal  cavity  is  called  "  Ascites,"  or  "  Abdominal 
Dropsy."  It  is  an  accompaniment  or  sequela  of  numerous  different  forms 
of  disease;  but  depends  immediately  on  some  condition  which  modifies  the 
action  of  the  capillary  vessels,  and  in  some  cases  perhaps  of  the  lymphat- 
ics, of  the  peritoneal  membrane.  This  condition  may  be,  in  the  first 
place,  some  morbid  process  going  on  in  the  peritoneal  tissue,  and  affect- 
ing directly  its  minute  vessels;  or,  in  the  second  place,  some  impediment 
to  the  return  of  blood  from  them  existing  in  the  course  of  the  portal  sys- 
tem; or,  in  the  last  place,  some  impediment  to  the  return  of  blood  from 
them  connected  with  some  disease  affecting  generally  the  movement  of 
blood  in  the  systemic  veins.  Among  the  first  of  these  classes  may  be 
included  peritonitis,  peritoneal  tuberculosis,  and  peritoneal  cancer;  among 
the  second,  tumors  or  other  growths  obstructing  the  trunk  or  main 
branches  of  the  vena  portae,  chronic  congestion  and  induration  of  the  liver, 
lardaceous  disease  of  that  organ,  and  especially  cirrhosis;  and  among  the 
last,  heart  disease,  Bright's  disease,  some  affections  of  the  lungs,  and  per- 
haps some  forms  of  anaemia. 

(1)  Acute  peritonitis,  like  acute  inflammation  of  other  serous  mem- 
branes, is  doubtless  attended  in  most  cases  with  more  or  less  effusion  of 
serum;  but  the  effusion  is  rarely  abundant  and  rarely  amounts  to  what 
would  be  recognized  during  life  as  Ascites.  Not  very  infrequently,  how- 
ever, when  the  acute  peritonitic  symptoms  have  subsided,  and  the  patient 
appears  to  be  convalescent  or  even  well,  abdominal  dropsy  slowly  super- 
venes. Ascites  is  especially  apt  to  occur  in  women  in  whom  the  peri- 
toneal inflammation  has  been  connected  with  some  inflammatory  condi- 
tion of  the  pelvic  organs.  It  is  frequently  associated  with  the  growth  of 
cystic  ovarian  tumors;  and  is  then  in  some  cases  due  either  to  the  occa- 
sional rupture  of  small  superficial  cysts,  or  to  the  establishment  of  more 
extensive  communications  between  the  cavities  of  the  ovary  and  that  of 
the  peritoneum,  and  the  discharge  of  fluid  from  the  thus  exposed  secreting 
surfaces  into  the  abdominal  cavity.  In  all  these  cases  the  peritonitis 
assumes  a  sub-acute  or  chronic  character.  Tubercular  deposits  in  connec- 
tion with  the  peritoneal  surface  are  another  fruitful  cause  of  Ascites.  In 
13  out  of  the  48  cases  of  tubercular  peritonitis  analyzed  on  a  former 
page,  this  condition  was  present,  and  several  of  them  had  been  tapped. 
Abdominal  cancer,  again,  is  frequently  attended  with  dropsical  effusion. 
Of  the  22  cases  of  peritoneal  cancer  previously  considered,  11  had  Ascites 
in  a  greater  or  less  degree;  and  it  may  be  added,  that  dropsy  not  infre- 
quently attends  cancerous  disease  of  the  ovaries  and  other  pelvic  organs, 
15 


226         DISEASES    OF   TIIE   INTESTINES    AND    PERITONEUif. 

and  of  the  mesenteric  or  retro-peritoneal  glands.  In  what  degree  Ascites, 
dependent  on  disease  of  the  peritoneal  membrane,  may  be  due  severally 
or  collectively  to  direct  involvement  of  the  capillaries  and  minute  veins 
of  that  membrane,  to  obstruction  of  the  lymphatic  orifices  which  seem 
now  proved  to  exist  there,  or  to  increased  functional  activity  on  the  part 
of  the  epithelial  cells,  is  not  very  easy,  perhaps,  to  decide;  but  there  \h 
probably  little  doubt  that  in  some  cases  in  which  there  is  infiltration  and 
contraction  of  the  peritoneal  folds,  especially  of  the  mesentery,  the 
larger  veins  contained  within  them  become,  as  Oppolzer  suggests, 
obstructed,  and  that  the  Ascites  is  produced  or  augmented  by  this  obstruc- 
tion. 

(2)  Impediment  to  the  passage  of  blood  along  the  portal  vessels,  with 
consequent  Ascites,  may  be  caused  by  various  morbid  conditions;  occa- 
sionally by  the  pressure  on  the  vena  portre  of  an  aneurismal,  hydatid,  or 
cancerous  tumor,  originating  externally  to  the  liver;  more  frequently  by 
the  pressure  of  cancerous,  "  knotty,"  syphilitic  or  hydatid  tumors  devel- 
oped in  the  hepatic  substance,  and  especially  by  cancerous  and  fibroid 
growths  occupying  the  lesser  omentum,  and  extending  thence  into  the 
liver  along  the  capsule  of  Glisson;  but  most  commonly  by  some  general 
hepatic  disease  which  involves  the  hepatic  capillaries  and  the  minute  veins 
which  open  into  and  emerge  from  them.  Of  the  diseases  last  referred  to, 
cirrhosis  is  the  most  frequent  and  the  most  important.  Cirrhosis,  how- 
ever, though  doubtless  tending  in  all  cases  ultimately  to  cause  Ascites,  is 
sometimes  fatal  by  ha?matemcsis  before  any  dropsical  effusion  has  taken 
place,  and  is  not  infrequently  found  to  be  present,  unsuspected,  in  death 
from  other  visceral  diseases.  Out  of  forty-six  cases  in  which  cirrhosis 
was  discovered  post  mortem,  in  twenty  only  was  there  more  or  less  accu- 
mulation of  ascitic  fluid.  The  presence  of  a  fibroid  capsule,  surrounding 
the  liver,  compressing  it,  and  squeezing  it  into  a  comparatively  small 
rounded  mass,  produces  the  same  effect.  This  formation,  which  is  proba- 
bly of  inflammatory  origin,  is  sometimes  associated  with  cirrhosis,  or  other 
morbid  states  of  the  liver,  but  is  sometimes  present  when  the  liver  seems 
otherwise  perfectly  healthy,  and  where  it  is  the  sole  visible  pathological 
phenomenon  associated  with  Ascites.  There  is  no  doubt  that  lardaceous 
disease  of  the  liver  also  sometimes  leads  to  abdominal  effusion,  and  not 
improbably  an  extreme  state  of  fatty  deposition  may  have  the  same  result; 
but  in  both  of  these  cases  the  hepatic  affection  is  almost  always  associated 
with  still  more  serious  disease  in  other  organs,  which  is  itself  capable  of 
causing  dropsy,  so  that  the  influence  of  the  liver  in  its  causation  is  ren- 
dered somewhat  diflScult  of  identification.  Similarly,  it  is  quite  certain 
that  chronic  induration  and  congestion  of  the  liver,  and  especially  that 
condition  of  the  organ  to  which  the  name  "  nutmeg  liver"  is  applied,  are 
frequently  instrumental  in  the  production  of  Ascites,  although  they  are 
themselves  always  secondary  to  dropsy-producing  diseases,  such  as  kidney 
disease,  heart  disease,  chronic  bronchitis  and  chronic  phthisis. 

(3)  All  the  diseases  which  have  just  been  enumerated,  viz.  chronic 
bronchitis  and  phthisis,  heart  diseases,  and  certain  forms  of  kidney  dis- 
ease, which  cause  anasarca,  cause  naturally,  as  a  part  of  that  anasarca, 
effusion  of  serum  into  the  abdominal  cavity:  but  in  most  cases  the  abdom- 
inal effusion  is  proportional  only  to  the  effusion  in  other  parts,  and  fails  to 
be  recognized  as  Ascites.  In  some  cases,  however  the  dropsical  accumu- 
lation in  the  abdomen  becomes  excessive,  while  that  elsewhere  undergoes 
but  little  increase.  When  this  happens,  it  is  usually  in  connection  with, 
and  then  probably  immediately  dependent  on,  some  abdominal  complica- 


ASCITES.  227 

tion  of  the  primary  disease,  especially  a  congested  or  indurated,  or  nut- 
meg, or  even  a  cirrhosed  condition  of  the  liver,  or  chronic  inflammation  of 
the  general  peritoneal  surface,  or  of  that  of  the  liver.  But  sometimes, 
even  where  the  ascitic  fluid  has  been  so  abundant  as  to  need  removal  by 
operation,  no  trace  of  disease  in  any  of  the  abdominal  tissues  or  viscera 
can  be  discovered.  There  can  be  little  doubt  that  in  some  forms  of  ca- 
chexia and  aui^mia,  in  which  without  there  being  any  apparent  visceral  dis- 
ease anasarca  takes  place.  Ascites  also  occasionally  ensues.  Yet  it  may 
be  remarked,  that  as  cases  of  this  kind  usually  get  well,  it  must  generally 
remain  a  matter  of  uncertainty  as  to  whether  or  not  there  may  have  been 
some  slight  inflammatory  affection  of  the  peritoneum,  or  some  other  evan- 
escent local  morbid  condition  on  which  the  Ascites  may  have  depended. 

It  may  be  added  here,  that  in  a  very  large  proportion  of  cases  of  As- 
cites, several  or  even  many  organs  are  diseased  at  the  same  time,  so  that 
it  becomes  difficult  or  impossible  to  determine  upon  what  exactly  the 
ascitic  accumulation  depends.  Thus  fibroid  and  lardaceous  and  other  de- 
generations often  affect  simultaneously  many  organs,  so  that  together 
with  the  liver  we  often  find  the  kidneys,  the  spleen,  the  lungs,  the  heart, 
the  blood-vessels,  diseased  in  various  degrees.  Besides  which,  in  all  such 
cases  there  is  a  great  tendency  to  inflammatory  implication  of  the  perito- 
neum as  well  as  of  other  serous  membranes;  and  tuberculosis  is  often 
present.  This  simultaneous  affection  of  many  different  organs  and  tis- 
sues is  specially  common  among  those  who  have  passed  a  life  of  debauch- 
ery, among  those  who  have  labored  under  the  syphilitic  cachexia,  and 
among  those  who  have  suffered  long  from  bone-disease,  from  protracted 
suppuration,  or  from  chronic  tuberculosis. 

The  amount  of  fluid  present  in  Ascites  may  vary  from  a  few  pints  up 
to  four  or  five  gallons,  and  indeed  much  larger  quantities  are  recorded  as 
having  been  met  with.  The  fluid  itself  is  for  the  most  part  slightly  viscid, 
transparent,  of  a  yellowish  or  greenish  tinge,  alkaline  and  containing  both 
albumen  and  fibrine  (or  fibrinogen).  It  may,  however,  under  different 
circumstances,  become  very  viscid,  opaline,  or  opaque  from  inflammatory 
products,  or  it  may  contain  blood. 

It  would  he  tedious  and,  it  is  feared,  useless  to  go  at  any  length  into 
the  statistics  of  Ascites;  for  in  the  first  place  Ascites  is  an  incident  only 
of  many  different  forms  of  disease,  the  statistics  of  which,  with  those  of 
their  particular  relations  to  abdominal  dropsy,  are  all  elsewhere  sufficiently 
discussed;  and,  in  the  second  place,  to  bring  together  the  statistics  of 
Ascites  in  the  gross,  would  be  to  combine  a  number  of  heterogeneous 
figures  the  manipulation  of  which  could  for  the  most  part  only  lead  to 
useless  or  fallacious  results.  There  are  a  few  facts,  however,  which  the 
statistics  of  a  general  hospital  have  supplied  me  with,  which  it  may  be 
worth  while  to  state.  According  to  these  statistics,  there  is  little  differ- 
ence between  males  and  females  as  regards  their  respective  degrees  of 
liability  to  Ascites,  although  undoubtedly  hepatic  dropsy  is  far  more  com- 
mon in  men  than  in  women;  Ascites  is  most  frequent  in  the  decades  from 
thirty  to  forty  and  from  forty  to  fifty,  next  in  those  from  twenty  to  thirty 
and  from  fifty  to  sixty;  but  it  is  not  uncommon,  both  above  the  latter  age 
and  in  young  children;  it  occurs  with  about  equal  frequency  as  the  result 
of  hepatic  disease,  heart  disease,  and  kidney  disease  (in  the  latter  two 
cases,  however,  generally  combined  with  a  congested  or  nutmeg  or  con- 
tracted condition  of  liver) ;  it  is  from  about  one-half  to  one-third  as  com- 
mon as  a  consequence  of  peritoneal  cancer,  peritoneal  tubercle,  bronchitis 
and  phthisis  severally;  and,  again,  occurs  in  association  with  lardaceous 


228  DISEASES    OF   THE    INTESTINES    AND    PERITONEUM. 

disease  of  organs  and  ovarian  cystic  tumors  respectively  about  half  as  fre- 
quently as  in  connection  with  each  of  the  immediately  foregoing  diseases. 

The  prospect  of  the  duration  of  Ascites,  and  of  eventual  recovery  or 
death,  necessarily  depends  almost  entirely  upon  the  nature  of  the  disease 
on  which  the  dropsy  depends.  Now,  most  of  the  diseases  causing  abdom- 
inal dropsy  are  from  their  nature  lethal,  and  generally,  therefore,  As- 
cites must  be  regarded  as  a  symptom  terminable  only  with  death.  Yet 
even  in  some  of  these  cases  it  is  of  very  protracted  duration,  and  relief 
may  be  afforded  several  times  by  tapping  before  the  arrival  of  the  fatal 
issue.  But  in  some  cases,  and  even  when  the  disease  causing  it  is  usually 
a  progressive  disease,  in  chronic  peritonitis,  in  cirrhosis,  in  the  encapsuled 
state  of  liver,  and  probably  also  in  tubercular  peritonitis,  the  dropsy  may 
be  sometimes  arrested  in  its  progress,  or  even,  temporarily  at  least,  re- 
covered from.  In  some  cases  indeed,  both  in  children  and  in  adults,  re- 
covery from  Ascites  (the  cause  of  which  thus  necessarily  remains  more  or 
less  obscure)  is  permanent. 

Symptoms. — The  symptoms  due  to  Ascites  alone  are  very  simple  and 
very  characteristic  of  the  affection.  The  accumulation  of  fluid  within  the 
abdominal  cavity  causes  the  abdomen  to  enlarge  and  become  tense,  and 
then  sooner  or  later  compresses  and  obstructs  the  intra-abdominal  veins, 
especially  those  connected  with  the  lower  extremities,  impedes  the  move- 
ments of  the  diaphragm,  inducing  difficulty  of  breathing,  and  interferes 
more  or  less  injuriously  with  the  healthy  action  of  the  abdominal  viscera. 
It  modifies  also  the  patient's  gait,  making  him  walk  like  a  pregnant 
•woman,  with  his  legs  wide  apart,  and  his  head  and  shoulders  thrown  back. 

The  presence  of  fluid  in  the  peritoneal  cavity  is  generally  easy  of  de- 
tection. The  abdomen  becomes  large,  uniformly  rounded,  but  with  a 
tendency  to  spread  or  bulge  in  the  flanks  as  the  patient  lies  on  his  back, 
tense  and  more  or  less  smooth  and  shining,  often  presenting  distended 
superficial  veins  and  the  linear  lacerations  of  the  deeper  tissues  of  the 
skin  which  are  so  common  in  pregnancy.  The  stomach  and  intestines 
being  lighter  than  the  fluid,  tend  to  float  on  its  upper  surface;  and  hence 
generally  the  highest  part  of  the  abdomen  according  to  the  patient's  po- 
sition, is  resonant,  while  the  more  dependent  parts  are  dull,  the  line  of 
demarcation  between  them  being  for  the  most  part  well-defined  and  hori- 
zontal: hence,  too,  as  the  patient  changes  his  position,  the  fluid  and  the 
floating  bowels,  and  necessarily  therefore  the  areas  of  resonance  and  dul- 
ness,  change  their  positions  relatively  to  the  abdominal  parietes.  It  may 
be  added  that  the  liver,  which  is  generally  if  not  always  of  higher  specific 
gravity  than  dropsical  fluid,  retreats  sometimes  distinctly,  as  the  pa- 
tient lies  on  his  back,  from  the  anterior  surface  of  the  abdomen,  a  stratum 
of  fluid  with  sometimes  a  loop  of  floating  bowel  occupying  the  interval. 
The  presence  of  fluid  is  further  and  very  importantly  indicated  by  the 
peculiar  thrill  which  is  experienced  by  the  hand  laid  flat  on  the  abdomen 
when  a  ripple  or  wave  is  produced  in  the  ascitic  fluid  by  a  slight  tap  or 
fillip  applied  to  some  other  part  of  the  abdominal  surface.  These  signs, 
however,  are  not  always  all  present,  or  at  least  easy  to  recognize:  and  not 
infrequently  tumors  and  other  forms  of  disease  simulate  or  mask  abdomi- 
nal dropsy.  Thus  when  the  ascitic  fluid  is  in  small  quantity  and  occupies 
probably  the  pelvis  only,  the  presence  of  dulness  will  scarcely  be  detected 
m  any  ordinary  position  which  the  patient  may  assume:  it  may  generally, 
however,  be  certainly  recognized  if  he  be  made  to  rest  upon  his  elbows 
and  knees  so  as  to  allow  the  fluid  to  gravitate  to  the  neighborhood  of  the 
umbilicus.     Thus,  again,  when  peritoneal  adhesions  are  present,  both  the 


ASCITES.  229 

eviden  5e  derivable  from  the  relative  positions  of  resonance  and  dulness, 
and  the  variability  of  these  positions,  and  that  also  derivable  from  fluctu- 
ation, may  wholly  fail  us.  Thus  too  when  the  abdomen  is  enormously 
distended,  the  attachment  of  the  stomach  and  intestines  may  be  too  short 
to  allow  of  any  of  these  parts  reaching  the  surface  of  the  abdomen  and 
the  dulness  may  be  universal,  a  condition  which  does  not  indeed  throw 
any  difficulty  in  the  way  of  ascertaining  the  existence  of  fluid,  but  may 
make  it  not  quite  easy  to  determine  whether  the  fluid  is  free  in  the  ab- 
dominal cavity  or  whether  it  is  contained  in  a  large  ovarian  cyst.  It  need 
scarcely  be  said  that,  independently  of  the  evidence  afforded  by  the  his- 
tory of  the  case,  by  the  form  of  the  abdomen,  and  by  vaginal  examination, 
there  is  always  in  ovarian  dropsy  (unless  indeed  it  be  associated  with  As- 
cites) resonance  in  one  or  other  or  both  flanks  in  consequence  of  the  posi- 
tion which  the  tumor  always  takes  in  relation  to  the  bowels;  yet  to  in- 
sure accuracy  it  must  not  be  forgotten  that  even  in  Ascites  there  may  be 
a  line  of  resonance  in  either  flank  due  to  the  presence  there  of  the  colon. 
It  must  be  added  that  cedema  of  the  abdominal  walls,  or  fat  in  them  or  in 
the  mesentery,  or  the  presence  of  diffused  peritoneal  cancer,  are  often 
serious  impediments  to  the  accurate  diagnosis  of  moderate  dropsical  accu- 
mulations. 

In  most  cases  peritoneal  dropsy  causes  merely  that  uniform  distention 
of  the  abdomen  which  has  been  above  described;  but  the  distending  force 
naturally  exerts  its  most  marked  influence  on  those  parts  of  the  parietes 
which  are  weakest;  and  hence  hernial  sacs  become  often  very  greatly 
dilated  and  attenuated,  especially  perhaps  the  sacs  of  umbilical  herniai; 
hence,  too,  in  some  cases  of  Ascites  in  females  the  recto-vaginal  pouch  be- 
comes greatly  distended,  and  even  protruded  through  the  vulva  in  the 
form  of  a  tumor,  carrying  with  it  as  a  covering  the  posterior  wall  of  the 
vagina.  I  recollect  one  case  in  which  the  formation  of  such  a  tumor 
caused  not  only  prolapse  of  the  whole  of  the  posterior  wall  of  the  vagina, 
but  also  of  the  upper  part  of  the  anterior  wall  together  with  the  os  uteri, 
which  latter  was  found  on  the  convexity  of  the  tumor.  The  body  of  the 
uterus  retained  its  normal  position,  but  its  neck  had  by  the  traction  ex- 
erted on  it  by  the  gradual  descent  of  the  posterior  wall  of  the  vagina  been 
attenuated  and  drawn  out  to  a  length  of  three  or  four  inches.  Occasion- 
ally Ascites  has  been  relieved  by  the  spontaneous  rupture  or  perforation  of 
some  thinned  portions  of  the  abdominal  parietes. 

QEdema  of  the  lower  extremities  and  intervening  parts  is  a  very  gen- 
eral and  early  accompaniment  of  abdominal  dropsy.  Sometimes  it  occurs 
at  so  early  a  period  as  to  be  the  first  symptom  of  disease  which  the  pa- 
tient himself  recognizes,  and  indeed  it  is  not  very  uncommon  for  ascitic 
patients  to  assert  that  their  illness  began  with  swelling  of  the  legs. 
There  is  no  doubt  that  in  dropsy  from  abdominal  disease  this  complication 
is  due  to  the  impediment  to  the  return  of  blood  produced  by  the  pressure 
of  the  ascitic  fluid  on  the  iliac  veins.  It  increases  for  the  most  part  with 
the  increase  of  the  conditions  on  which  it  depends;  and  may  become  as 
excessive  as  that  from  cardiac  or  renal  disease;  but  it  rarely  extends  be- 
yond the  part  with  which  the  mechanically-impeded  veins  are  immediately 
connected,  and  never  becomes  general.  It  need  scarcely,  however,  be 
said,  that  when  Ascites  is  connected  with  diseases  of  the  heart,  lungs,  or 
kidneys,  general  anasarca  is  very  often  present.  Anasarca  due  to  abdom- 
inal dropsy  is  generally  equal  in  the  two  lower  limbs;  and  in  this  respect 
differs  for  the  most  part  from  anasarca  in  the  legs  resulting  from  abdomi- 
nal tumors  or  from  obstruction  by  clot  of  the  iliac  veins. 


230         DISEASES    OF   THE   INTESTINES    AND   PEEITONEUM. 

Shortness  of  breath  is  an  early  symptom,  and  it  increases  with  the  in- 
crease of  the  dropsy.  It  is  not  always  noticed  by  the  patient  himself 
while  he  remains  quiet  in  the  sitting  or  semi-recumbent  posture.  But 
even  at  such  times  the  physician  will  probably  observe  that  the  respiratory 
acts  are  unduly  quick  and  shallow.  Ultimately,  however,  this  symptom 
becomes  very  painful  and  distressing.  It  is  obviously  causecl  ':»y  the  en- 
croachment of  the  enlarging  abdomen  upon  the  thoracic  cavity,  by  which 
the  diaphragm  becomes  pushed  up  and  prevented  from  performing  the 
movements  necessary  for  perfect  respiration.  The  lower  portions  of  the 
lungs  become  consequently  more  or  less  empty  of  air  and  collapsed;  and, 
as  might  be  anticipated  from  a  knowledge  of  its  cause,  it  is  also  much  ag- 
gravated when  the  patient  lies  down. 

Although  in  the  earlier  stages  there  may  be  little  or  no  abdominal  dis- 
comfort, there  generally  arises  in  the  course  of  the  affection  a  good  deal 
of  aching,  which  is  usually  complained  of  most  in  the  flanks  and  across  the 
epigastric  or  umbilical  regions.  This  is  probably  due  to  the  pressure  which 
the  fluid  exerts  on  the  various  tissues,  but  more  particularly  to  that  which 
it  exerts  on  the  hollow  viscera.  This  pain  is  sometimes  associated  with 
that  of  distinct  colic,  and  not  very  infrequently,  when  the  abdomen  has 
become  very  largely  distended,  with  pain  of  a  peritonitic  cliaracter.  In- 
deed, acute  or  sub-acute  peritonitis  is  far  from  rare  in  the  latter  stages  of 
Ascites.  It  may  be  added,  that  diarrhoea  is  not  uncommon  in  the  course 
of  Ascites,  and  that  it  seems  to  be  sometimes  due  to  the  same  impediment 
to  the  portal  circulation  which  causes  the  Ascites  itself,  and  is  sometimes 
dependent  on  some  slight  dysenteric  inflammation;  and  that  although  early 
in  the  affection  there  may  be  no  visible  morbid  condition  of  tongue  and 
neither  thirst  nor  loss  of  appetite,  the  tongue  and  the  digestive  functions 
after  a  while  all  become  variously  and  more  or  less  seriously  affected.  It 
may  be  added  further,  that  patients  almost  invariably  complain  of  flatu- 
lency, a  complaint  which  is  undoubtedly  due  in  many  cases  to  excessive 
flatulent  distention  of  the  bowels,  but  may  in  some  degree  be  explained 
by  the  discomfort  which,  in  the  presence  of  much  ascitic  fluid,  even  a  nor- 
mal amount  of  gaseous  distention  may  occasion.  There  is  generally  some 
dryness  of  skin  and  some  diminution  in  the  urinary  secretion. 

There  are  many  symptoms,  more  or  less  grave,  besides  those  which 
have  been  considered,  which  may  be  presented  by  ascitic  patients;  but 
they  are  symptoms  for  the  most  part  due  to  the  diseases  upon  which  the 
Ascites  itself  depends,  and  are  sufficiently  considered  elsewhere  under  the 
heads  of  those  diseases. 

Treatment. — The  treatment  of  Ascites,  in  a  large  proportion  of  cases, 
merges  in  the  treatment  of  the  disease  by  which  it  has  been  caused.  Still, 
in  some  cases  from  the  very  beginning,  and  in  most  when  the  accumula- 
tion becomes  very  great,  special  treatment  directed  against  the  Ascites  is, 
or  appears  to  be,  called  for.  To  promote  the  absorption  and  removal  of 
the  ascitic  fluid  there  are  good  theoretical  reasons  for  the  employment  of 
those  remedial  measures  which  increase  the  discharges  from  the  skin,  the 
kidneys,  and  the  bowels.  The  skin  in  cases  of  Ascites  is  usually  unnatu- 
rally dry,  and  this  fact  seems  to  furnish  an  additional  argument  in  favor 
of  the  use  of  diaphoretics.  There  is  no  doubt,  indeed,  that  diaphoretio 
remedies  are  very  generally  beneficial  to  the  patient.  And  amongst 
these  must  not  be  forgotten  the  most  powerful  of  all,  namely,  the  hot- 
bath,  the  vapor-bath,  and  the  Turkish  bath.  Again,  the  frequent  diminu- 
tion in  the  urinary  secretion  may  be  urged  as  a  further  motive  for  the 
employment  of  diuretics;  and  again,  it  may  be  stated  generally  that  the 


ASCITES.  281 

promotion  of  the  flow  of  urine  is  serviceable.  Still  more,  tlie  close  con- 
nection between  the  peritoneal  membrane  and  the  mucous  lining  of  the 
bowels,  and  the  fact  that  in  hepatic  obstructions  the  mesenteric  capillaries 
sometimes  relieve  themselves  by  discharge  of  serum  at  the  serous  surface, 
sometimes  by  the  escape  of  serum  or  blood  at  the  mucous  surface,  would 
seem  to  be  decisive  as  to  the  value  of  purgatives,  and  more  especially  of 
watery  purgatives;  and  it  may  be  freely  admitted  that  purgatives  are 
very  often  beneficial.  I  must  confess,  however,  that  although  fully  ac- 
quiescing in  the  importance  of  restoring  as  far  as  may  be,  and  of  main- 
taining, the  healthy  action  of  the  skin  and  kidneys,  and  of  promoting  a 
tolerably  free  action  of  the  bowels,  I  have  never,  to  the  best  of  my  recol- 
lection and  belief,  seen  an  ascitic  patient  materially  relieved  as  regards  hi» 
Ascites,  far  less  cured,  by  a  course  of  either  diaphoretics,  diuretics,  or 
purgatives.  And  in  respect  to  purgatives,  I  may  add  that  I  have  fre- 
quently had  to  discard  them  because,  while  they  were  not  distinctly  bene- 
fiting the  dropsy,  they  were  obviously  affecting  the  patient's  health  inju- 
riously; and  further,  that  according  to  my  own  experience,  diarrhoea  is  a 
not  infrequent  concomitant  of  Ascites,  and  is  often  difficult  to  arrest,  and 
often  of  bad  augury.  There  are,  however,  certain  medicines  which  are 
more  or  less  diuretic  in  their  action  which  have  been,  or  are,  supposed  to 
have,  occasionally  at  least,  a  specific  influence  over  dropsical  accumula- 
tions in  serous  membranes,  and  under  the  use  of  which  occasional  recov- 
eries are  recorded.  Among  these  may  be  enumerated  mercury,  iodide  and 
bromide  of  potassium,  copaiba,  and  the  combination  of  fresh  squills  and 
crude  mercury. 

But  it  must  be  repeated  that,  as  a  rule,  the  treatment  which  is 
directed  towards  the  alleviation  or  cure  of  the  disease  or  condition  of 
health  to  which  the  Ascites  is  secondary,  is  that  which  is  most  likely  to 
be  curative  as  regards  the  dropsy.  The  modes  of  treating  heart  diseases, 
kidney  diseases,  bronchitis,  cirrhosis,  and  so  on,  need  not  be  here  discussed; 
but  it  may  be  pointed  out  that  in  a  considerable  number  of  cases  of  As- 
cites, and  even  in  many  of  those  in  which  the  Ascites  is  dependent  on  the 
diseases  which  have  just  been  enumerated,  there  is  present  a  greater  or 
less  degree  of  anoemia  and  want  of  tone,  and  that  in  some  at  least  of 
these  cases  annemia  and  want  of  tone  are  in  some  degree  instrumental  in 
producing  the  dropsy.  It  is  certain  that  tonics  are  very  often  well  borne 
by  ascitic  patients,  and  that  even  when  not  well  borne  at  first  a  little 
judiciousness  in  their  employment,  or  in  the  employment  of  other  prepara- 
tory measures,  will  render  them  tolerable ;  and  it  is  certain  that  under  their 
use  ascitic  patients  do  often  not  only  improve  in  health,  but  lose,  in  part  or 
wholly,  their  dropsical  accumulation,  and  that  occasionally  the  recovery  is 
i:)ermanent,  and  permanent  even  after  the  performance  of  paracentesis. 
Quinine,  iron,  and  cod-liver  oil  are  probably  the  most  valuable  forms  of 
tonics. 

Counter-irritants  and  other  forms  of  local  applications  are  doubtless 
sometimes  useful  for  the  relief  of  uneasiness  and  pain;  but  no  such  appli- 
cations are  of  use  in  promoting  absorption  of  the  fluid.  But  when  the 
abdomen  has  become  very  much  distended,  and  the  patient  is  suffering 
seriously  from  the  inconvenience  and  distress  which  attend  such  disten- 
tion, the  removal  of  the  dropsical  fluid  by  paracentesis  becomes  neces- 
sary. The  time  for  the  performance  of  this  operation  must  be  determined 
for  each  case,  less  by  the  actual  distention  of  the  belly  than  by  the  grav- 
ity of  the  symptoms  which  attend  that  distention.  The  operation  is  gen- 
erally postponed  as  long  as  possible,  and  I  believe  rightly;  but  it  may  be 


232         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

worthwhile  to  state  that  it  has  not  very  infrequently  appeared  to  me  that 
the  beneficial  effects  of  remedies  have  been  exerted  in  a  much  greater  degree 
after  paracentesis  than  while  the  belly  was  largely  distended.  Paracen- 
tesis is  generally  a  harmless  operation;  but  sometimes  peritonitis  ensues, 
and  is  apt  to  be  rapidly  fatal.  I  believe  that  in  cases  of  peritoneal  dropsy 
dependent  on  cancerous  disease  of  the  abdomen  tapping  is  not  only  very 
rarely  of  even  temporary  benefit,  but  that  it  generally  hastens  death. 
Iodine  and  other  substances  have  occasionally  been  injected  into  the  per- 
itoneum for  the  cure  of  Ascites,  and  successful  cases  of  this  hazardous 
kind  of  treatment  are  recorded. 


ABDOMINAL    TUMORS. 

By  S.  O.  Habershon,  M.D. 


Before  proceeding  to  the  consideration  of  true  abdominal  tumors,  it 
may  be  well  to  notice  those  which  are  of  a  delusive  character,  and  have 
been  called  by  Dr.  Addisorf  and  Sir  Wm.  Gull  ^'phantom  tumors.''''  It  is 
a  common  thing  for  patients  to  suppose  that  there  is  something  seriously 
wrong  because  one  portion  of  the  abdominal  walls  projects  more  promi- 
nently than  another;  sometimes  the  left  hypochondrium  is  found  to  be 
enlarged  from  a  flatulent  stomach,  or  the  csecum  or  sigmoid  flexure  from 
similar  gaseous  distention,  or  the  abdominal  wall  yields  so  as  to  form  a 
direct  protrusion;  these  conditions  are  easily  recognized:  the  part  is  found 
to  be  flatulent  on  percussion,  and  manipulation  fails  to  detect  any  solid 
growth;  but  in  the  "phantom  tumor"  a  solid  mass  is  felt,  but  it  is  in  the 
parietes,  and  it  is  due  to  muscular  contraction;  the  part  is  hard  and  dense, 
and  may  be  readily  mistaken;  it  is,  however,  fairly  resonant  on  percussion, 
and  by  gentle  and  continued  manipulation  the  muscle  relaxes;  if  the  hand 
be  gently  placed  on  the  hard  mass,  and  the  attention  of  the  patient  di- 
verted by  conversation  of  an  absorbing  character,  at  the  same  time  that 
the  fingers  are  gently  moved  about  the  mass,  the  hardness  disappears. 
This  contraction  of  the  muscular  walls  may  be  found  at  any  part;  some- 
times it  is  on  the  right  side,  and  the  patient  seems  to  have  enlargement 
of  the  liver;  frequently  it  is  one  of  the  transverse  muscular  bands  of  the 
rectus,  sometimes  it  is  the  quadratus  lumborum,  or  the  transversalis  mus- 
cle of  the  abdomen. 

It  is  scarcely  correct  to  speak  of  a  loose  kidney  as  a  **  phantom  tumor; " 
it  is  a  movable  one,  but  it  does  not  entirely  disappear  by  pressure,  although 
it  may  pass  beyond  the  reach  of  the  hand. 

It  is  important  in  the  study  of  abdominal  tumors  to  have  a  definite 
acquaintance  with  the  exact  position  of  the  abdominal  viscera.  For  the 
convenience  of  description,  the  abdomen  is  divided  into  several  regions 
marked  out  by  lines  from  fixed  points.  A  line  drawn  round  the  upper 
part  of  the  abdomen  at  the  most  prominent  part  of  the  costal  cartilages, 
and  a  second  at  the  crest  of  the  ileum,  divide  the  surface  into  three  zones, 
and  these  again  by  two  perpendicular  lines  are  subdivided  each  into  three 
other  spaces,  the  lines  passing  downwards  from  the  cartilage  of  the  eighth 
rib  to  the  middle  of  Poupart's  ligament.  In  the  upper  zones  we  have  the 
right  and  left  hypochondriac  regions,  on  either  side  of  the  epigastric 
space  or  scrobiculus  cordis;  in  the  central  zone,  the  right  and  left  lumbar 
regions  are  on  either  side  of  the  umbilical,  and  below,  in  the  third  zone, 
the  right  and  left  iliac  are  situated  on  either  side  of  the  hypogastric  region. 


234         DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

During  health  these  regions  are  occupied  by  their  respective  viscera,  and 
it  is  useless  to  try  and  ascertain  abnormal  states,  unless  there  be  a  thorough 
knowledge  of  that  which  is  normal.  We  would  further  add  that  in  every 
case  of  abdominal  tumor  it  is  important  to  enquire:  1st,  into  the  general 
liistory  of  the  symptoms  of  the  patient;  2d,  to  ascertain  the  exact  position 
of  the  tumor,  and  the  physical  signs;  and  3d,  to  learn  whether  there  is 
any  functional  disturbance  of  the  abdominal  organs.  It  is  not  likely  that 
any  viscus  is  involved  in  a  morbid  growth,  if  it  perform  its  functions  in  a 
healthy  manner. 

It  may  be  well  to  consider  these  regions  as  regards  their  normal  and 
abnormal  contents.  The  right  hypochondrhtm  contains  especially  the 
liver  and  gall-bladder,  but  the  gland  passes  into  the  epigastric  region,  and 
reaches  the  left  hypochondrium;  when  enlarged  it  extends  into  the  um- 
bilical and  right  lumbar  regions.  The  liver  is  attached  to  the  diaphragm, 
and  to  a  certain  extent  moves  with  it.  It  reaches  upwards  as  high  as  the 
fifth  rib,  where  the  dulness  commences  and  is  partial;  at  the  sixth  rib  the 
dulness  is  complete;  when  the  patient  is  recumbent  the  liver  is  behind  the 
ribs,  unless,  as  is  generally  the  case  in  women,  it  has  been  pushed  down 
by  compression;  but  in  the  erect  and  sitting  postures  the  liver  may  be  felt 
an  inch  below  the  ribs.  Beside  the  liver  and  gall-bladder  the  right  hypo- 
chondrium contains  the  angle  of  the  ascending  colon,  part  of  the  duo- 
denum, the  right  supra-renal  capsule,  and  the  upper  part  of  the  right  kid- 
ney. It  must  be  remembered,  in  reference  to  enlargement  of  the  liver,  that 
the  gland  may  be  ptished  down  by  pleuritic  effusion.  In  large  effusions 
into  the  right  pleura  the  liver  is  always  displaced. 

2.  The  liver  may  be  pushed  down  by  effusion  between  the  upper  lobe 
and  the  diaphragm,  the  effusion  being  either  serous  or  purulent;  in  these 
cases  the  symptoms  may  closely  resemble  pleuritic  effusion.  Many  years 
ago  a  woman  was  admitted  under  my  care  into  Guy's  Hospital  with  severe 
peritoneal  symptoms  after  a  fall  from  a  cart  upon  the  abdomen.  The 
pain  was  great,  and  the  strength  gradually  gave  way.  On  examination 
of  the  lower  part  of  the  right  lung  before  death,  dulness  on  percussion, 
with  bronchial  breathing  and  modified  voice  sound,  was  heard,  and  some 
who  had  not  known  the  previous  history  believed  the  disease  to  be  above 
the  diaphragm.  On  the  post-mortem  table  a  trochar  was  introduced  be- 
tween the  ribs  posteriorly,  and  pus  exuded,  apparently  confirming  the  idea 
tliat  empyema  existed;  but  on  fuller  examination  it  was  found  that  the 
pus  was  situated  between  the  liver  and  the  diaphragm;  there  had  been 
peritonitis,  and  the  pus  was  circumscribed  by  adhesions, 

3.  The  liver  may  be  pushed  down  by  the  development  of  tumors,  or 
by  a  hydatid  cyst  in  the  right  lobe  of  the  liver.  This  cyst  or  tumor  may 
be  so  situated  behind  the  ribs  as  to  be  quite  beyond  the  reach  of  the  hand. 
A  woman  in  middle  life  was  admitted  under  my  care  into  Guy's  with  the 
liver  extending  into  the  umbilical  region,  the  surface  was  smooth,  the 
gland  passed  lower  into  the  abdomen,  and  the  strength  of  the  patient  at 
length  gave  way  and  she  sank.  On  examination,  when  the  abdomen  was 
o})ened,  the  liver  seemed  to  fill  the  greater  part  of  the  abdomen  on  the 
right  side;  the  surface  was  smooth,  and  it  was  only  when  the  gland  was 
drawn  down  from  the  diaphragm  that  the  true  nature  of  the  enlargement 
was  recognized.  An  enormous  hydatid  cyst  occupied  the  right  lobe  and 
pressed  in  every  direction,  but  did  not  reach  the  free  surface  of  the  liver. 
In  the  examination  of  an  enlarged  liver  the  patient  should  be  placed  on 
the  back,  the  knees  drawn  up,  and  the  head  comfortably  supported,  and 
the  patient's  attention  should  be  absorbed  by  conversation,  if  possible. 


ABDOMINAL   TUMORS.  235 

Sudden  pressure  •will  often  detect  an  enlarged  gland,  which  could  not  be 
recognized  by  gradual  pressure;  if  the  fingers  be  passed  upwards  from 
below,  the  edge  may  be  caught,  and  they  should  then  be  gently  passed 
over  the  gland  to  ascertain  whether  there  are  any  irregularities;  the 
surface  is  dull  on  percussion;  at  the  upper  part  where  the  liver  is  over- 
lapped by  lung  there  is  partial  resonance,  and  we  sometimes  find  that 
the  lower  edge  may  be  covered  by  the  colon,  and  resonance  is  thus  pro- 
duced. 

4.  Enlargement  of  the  gall-bladder  is  found  generally  opposite  the 
tenth  rib;  it  is  pyriform,  and  when  filled  with  bile  will  yield  somewhat  to 
pressure.  Sometimes  I  have  found  it  filled  with  a  great  number  of  gall- 
stones, so  that  it  resembled  a  solid  mass;  a  very  different  condition  was 
found  some  years  ago  in  a  case  under  the  late  Dr.  Babington,  the  speci- 
men of  which  is  in  Guy's  Museum;  the  gall-bladder  communicated  with 
the  intestine,  and  was  filled  with  gas,  so  that  there  was  resonance  on  per- 
cussion. 

5.  Enlargement  of  the  liver,  if  general,  arises  from  congestion,  from 
inflammation,  from  fatty  deposit,  from  lardaceous  disease,  from  obstruc- 
tion of  the  bile-ducts ;  if  local,  from  hydatid  tumor,  from  syphilitic  de- 
posit, from  cancerous  growths,  from  abscess  in  the  liver,  or  from  suppura- 
tion in  connection  with  the  bile-ducts. 

6.  An  enlargement  of  the  right  kidney  can  sometimes  be  felt  imme- 
diately below  the  right  lobe  of  the  liver;  it  will  be  found  to  extend  into 
the  loin. 

7.  Malignant  disease  of  the  right  supra-renal  capsule  may  also  reach 
the  lower  part  of  the  liver.  I  have  found  a  tumor  of  the  left  supra-renal 
capsule  simulating  enlargement  of  the  spleen. 

8.  Malignant  disease  of  the  pancreas  and  first  part  of  the  duodenum 
are  recognized  by  their  clinical  history;  the  hardness  may  be  felt  closely 
in  contact  with  the  liver. 

9.  Cancerous  disease  of  the  angle  of  the  ascending  colon  is  also  felt 
in  this  region;  in  this  disease  pain  comes  on  several  hours  after  food,  and 
there  is  likely  to  be  discharge  of  blood  or  of  mucus  from  the  bowels. 

In  the  epigastric  region  we  find  the  stomach  and  its  lesser  curvature, 
and  the  left  lobe  of  the  liver;  the  gall-bladder  and  the  pyloric  extremity 
of  the  stomach  are  situated  at  its  union  with  the  right  hypochondriac  re- 
gion; posteriorly  we  have  the  pancreas,  the  aorta,  the  vena  cava,  the  coe- 
liac  axis  and  the  commencement  of  its  large  branches;  at  the  lower  part 
of  this  region  we  have  the  transverse  colon,  varying,  however,  in  position 
according  to  the  distention  of  the  stomach.  We  would  remark  that  yield- 
ing of  the  parietes,  with  flatulent  distention  of  the  stomach,  often  gives 
rise  to  the  idea  of  tumor. 

2.  Abscess  sometimes  forms  in  the  parietes  in  this  part,  not  only  in  the 
muscular  parietes,  but  in  the  loose  cellular  tissue  about  the  end  of  the 
sternum.  In  a  case  of  that  kind,  in  the  clinical  ward  of  Guy's  some  years 
ago,  there  was  a  projection  at  the  scrobiculus  cordis,  which  was  afterwards 
found  to  be  an  abscess  which  extended  to  the  under  surface  of  the  dia- 
phragm. 

3.  Abnormal  pulsation  is  often  felt  at  the  epigastric  region ;  this  may 
arise  from  an  aneurismal  tumor  in  connection  with  the  aorta  or  with  the 
coeliac  axis;  in  aneurism  of  the  aorta  close  to  the  diaphragm  it  i.s,  how- 
ever, very  difficult  to  feel  the  aneurismal  tumor,  unless  it  be  of  large  size. 
In  the  majority  of  cases  a  pulsating  tumor  at  the  scrobiculus  cordis  is 
found  to  arise  from  disease  of  the  left  lobe  of  the  liver  pressing  upon  the 


236  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

abdominal  aorta;  in  other  cases  the  pulsating  mass  may  consist  of  a  vas- 
cular and  pulsating  medullary  growth  in  the  stomach. 

4.  Tumors  of  different  kinds  in  the  left  lobe  of  the  liver  are  found  in 
this  region. 

5.  Disease  at  the  lesser  curvature  of  the  stomach  may  not  only  be  felt 
in  this  region,  but  may  have  pulsation  communicated  to  it  from  the  aorta. 

6.  Chronic  ulcer  with  thickened  walls  may  constitute  the  tumor  felt 
at  the  epigastric  region;  but 

7.  A  hard  mass  felt  in  the  epigastrium  is  more  frequently  found  to  be 
malignant  disease. 

On  a  level  with  the  umbilical  line  and  situated  posteriorly  we  have  the 
pancreas,  but  so  deeply  is  the  gland  placed  that  it  is  difficult  to  recognize 
enlargement  by  digital  examination. 

Malignant  disease  of  the  pancreas,  where  there  is  much  enlargement, 
may  be  sometimes  recognized;  but  in  such  cases  we  principally  depend 
upon  the  clinical  history  and  the  general  symptoms,  in  forming  a  correct 
diagnosis.  In  a  case  of  inflammation  of  the  cellular  tissue  about  the  pan- 
creas, which  I  saw  in  consultation  some  years  ago,  there  was  a  hard  swell- 
ing felt  at  the  upper  part  of  this  region;  there  was  severe  pain,  with  fe- 
brile excitement,  and  I  supposed  the  case  was  one  of  gastric  disease;  post- 
mortem examination  showed  that  the  stomach  was  healthy,  but  that  the 
swelling  was  an  abscess  connected  with  the  pancreas. 

In  chronic  disease  of  the  omentum,  often  of  a  malignant  character,  the 
serous  membrane  is  puckered  and  drawn  upwards,  so  that  it  forms  a  firm 
band  passing  across  the  abdomen,  at  the  lower  part  of  the  epigastric  or  at 
the  upper  part  of  the  umbilical  region.  It  may  be  associated  with  malig- 
nant disease  of  the  peritoneum,  as  we  have  mentioned. 

In  the  left  hypochondrium  we  have  the  cardiac  extremity  of  the  stom- 
ach, the  spleen,  the  left  supra-renal  capsule,  and  a  portion  of  the  kidney. 
The  left  angle  of  the  colon  may  also  extend  to  this  space.  The  most 
common  tumor  found  in  this  region  is  the  spleen,  which,  as  it  increases  in 
size,  not  only  passes  upwards  and  raises  the  level  of  dulness  on  that  side, 
but  it  passes  downwards  and  is  also  directed  forwards.  This  forward  di- 
rection may  be  due  to  the  band  of  peritoneum  immediately  beneath  the 
gland;  but  there  is  no  doubt  of  the  fact  that  the  spleen,  as  it  increases, 
and  it  attains  sometimes  an  enormous  size,  passes  not  only  into  the  lum- 
bar but  also  into  the  umbilical  region.  The  fissure  at  the  anterior  edge 
assists  us  in  the  recognition  of  the  spleen;  but  this  is  not  a  certain  sign, 
for  the  fissure  between  two  enormously  enlarged  lymphatic  glands  may 
communicate  to  the  touch  the  same  impression.  The  spleen  enlarges 
after  a  full  meal;  it  may  increase  from  temporary  portal  congestion;  it  is 
felt  below  its  normal  position  in  enteric  and  other  fevers,  but  these  condi- 
tions would  not  be  designated  as  tumors.  It  is  in  the  enlargement  after 
ague,  in  leucocythemia,  in  lardaceous  disease,  that  we  find  the  spleen  to  at- 
tain to  very  large  proportions,  and  in  these  cases  the  increase  is  general. 
In  abscess,  in  hydatids,  and  in  malignant  disease,  the  enlargement  is  par- 
tial. 

2.  Another  tumor  in  the  left  hypochondrium  arises  from  enlargement 
of  the  left  kidney  or  from  hydatid  at  that  part;  but  in  this  case  the  growth 
extends  more  into  the  loin,  and  there  is  more  likelihood  of  distention  of 
the  lower  ribs  on  that  side. 

3.  Malignant  disease  of  the  supra-renal  capsule  on  the  left  side  some- 
times presses  forward  to  the  anterior  part,  and  is  felt  immediately  below 
the  spleen.     I  have  known  it  mistaken  for  an  enlargement  of  the  spleen 


ABDOMINAL   TUMORS.  237 

itself,  for  the  growth  was  large,  and  it  appeared  to  pass  from  beneath  the 
ribs. 

4.  Aneurismal  disease  at  the  commencement  of  the  descending  aorta 
sometimes  pushes  forward  the  spleen,  and  the  diagnosis  is  difficult.  In 
the  case  to  which  I  refer,  the  lower  ribs  were  prominent,  but  pulsation 
was  very  indistinct.  The  patient  died  from  rupture  of  the  aneurismal  sac 
behind  the  peritoneum. 

5.  The  solid  walls  of  an  ovarian  cyst  sometimes  reach  into  the  left 
hypochondrium,  form  a  tumor,  and  simulate  disease  of  the  spleen.  The 
tapping  of  the  cyst  would  be  one  means  of  diagnosis  of  a  case  of  this 
kind,  for  the  solid  portion  of  the  cyst  would  then  pass  towards  the 
pelvis. 

6.  It  is  scarcely  necessary  to  mention  the  manner  in  which  the  spleen 
may  be  pushed  down  by  effusions  both  into  the  pleura  and  into  the  peri- 
cardium. 

7.  Local  suppuration  may  occur  in  this  region,  and  produce  a  swelling 
resembling  a  tumor. 

The  next  zone  of  the  abdomen  is  divided  into  the  central,  the  umbili- 
cal, and  into  the  right  and  left  lumbar  spaces.  In  the  lumbar  regions 
the  kidneys  and  the  ascending  and  descending  colon  may  be  causes  of 
tumors.  The  kidneys  extend  to  the  loin,  and  as  they  pass  forward  can 
be  felt  anteriorly  to  the  inner  side  of  the  colon.  The  condition  of  the 
urine,  in  the  discharge  of  blood,  of  pus,  or  of  cancerous  cells,  affords  to 
us  an  important  guide  in  diagnosis.  A  tumor  from  distended  pelvis  of 
the  kidney  is  most  uncertain  as  to  its  size.  Sometimes  a  calculus  may 
block  up  the  ureter,  and  the  pelvis  of  the  kidney  gradually  attains  large 
dimensions,  till  at  length  the  ureter  is  distended  beyond  the  size  of  the 
obstructing  calculus,  and  a  sudden  discharge  of  several  pints  of  urine  at 
once  diminishes  the  size  of  the  tumor.  The  same  may  be  the  case  in  sup- 
puration of  the  kidney.  In  a  patient  under  my  care  in  Guy's,  a  large 
tumor  extended  from  the  right  lumbar  into  the  iliac  region,  and  would 
suddenly  subside  on  the  discharge  of  several  pints  of  urine.  This  con- 
dition came  on  when  the  patient  was  about  sixteen;  he  was  a  shoemaker, 
aud  although  he  had  several  severe  attacks,  he  continued  his  work  till  he 
was  nearly  sixty-four  years  of  age,  when  he  died  in  Guy's  Hospital  from 
a  large  cancerous  growth  which  affected  the  kidney  on  the  same  side. 
After  death  it  was  found  that  a  calculus  was  the  cause  of  the  obstruction 
of  the  ureter. 

2.  The  glands  in  connection  with  the  kidney,  the  lumbar  glands, 
sometimes  form  a  large  tumor  in  this  region;  the  urine  is  then  unaffected, 
the  growth  is  more  irregular,  and  there  are  generally  other  indications  of 
malignant  disease.  In  hydatid  disease  of  the  kidney  the  tumor  is  rounded 
and  elastic. 

3.  Accumulations  in  the  ascending  or  descending  colon  form  masses 
in  these  regions;  but  the  clinical  history,  the  absence  of  severe  symptoms, 
and  the  relief  by  purgative  medicine,  characterize  these  cases, 

4.  In  intussusception  a  doughy,  elongated  mass  may  be  felt  in  the  as- 
cending or  even  in  the  descending  colon.  The  severe  and  spasmodic  pain, 
the  vomiting  which  is  often  present,  the  obstruction  of  the  bowels,  and 
the  discharge  of  blood  and  of  mucus,  indicate  the  character  of  the  affec- 
tion. 

0.  In  diseases  of  the  spine  leading  to  suppuration  there  is  a  bulging 
in  the  loin,  and  it  may  be  a  projection  anteriorly,  which  can  be  felt  on 
digital  examination. 


238  DISEASES    OF   TUB   INTESTINES    AND    PERITONEUM. 

6.  Abscess  in  the  loin  and  in  the  quadratus  lumborum  muscle  may 
lead  to  enlargement,  and  may  extend  into  the  bowel.  Thus,  we  have 
known  an  abscess  pass  into  the  csecum,  and  have  seen  suppuration  pri- 
marily connected  with  the  bowel  reach  the  loin. 

7.  Ovarian  tumors  may  pass  from  the  iliac  fossa  into  the  loin,  but 
more  frequently  they  extend  into  the  umbilical  region. 

In  the  umbilical  region  we  have  the  transverse  colon  and  the  omentum 
attached  to  it,  the  small  intestine,  with  the  mesentery  and  mesenteric 
glands,  and  posteriorly  the  aorta  and  vena  cava.  On  either  side  are  the 
right  and  left  renal  vessels.  The  position  of  the  transverse  colon  varies 
greatly;  sometimes  its  curve  is  greatly  increased,  and  it  may  reach  nearly 
to  the  hypogastric  region.  The  curve  may  be  increased  as  the  conse- 
quence of  distention,  or  by  the  dragging  of  an  omental  hernia.  Tumor 
in  the  walls  of  the  intestine  also  changes  its  position. 

2.  Intussusception  of  the  small  intestine  is  often  found  in  the  umbil- 
ical region. 

3.  Tumors  in  the  omentum  and  in  the  mesentery.  In  the  former, 
the  mass  is  movable,  and  there  is  no  functional  disturbance  of  the  in- 
testine. 

4.  In  strumous  disease  of  the  intestine  the  bowels  are  often  matted 
together  by  inflammatory  adhesion,  and  the  mass  resembles  a  tumor. 
Sometimes  there  is  suppuration  or  fascal  abscess,  or  it  may  be  the  discharge 
takes  place  from  the  umbilicus. 

5.  Ovarian  tumors  are  often  found  to  extend  into  the  umbilical  re- 
gion. 

6.  Aneurismal  disease  of  the  aorta  and  the  branches  of  the  abdominal 
aorta  may  be  felt  in  this  space,  but  frequently  enlarged  glands,  pressing 
upon  the  aorta  or  upon  the  renal  arteries,  simulate  true  aneurismal  disease. 
Sometimes  we  can  remove  the  gland  from  the  pulsating  vessel  beneath, 
by  manipulation  or  by  changing  the  position  of  the  patient;  but  this  is 
not  invariably  the  case. 

In  studj'ing  enlargement  in  the  loins,  it  is  important  to  remember  that 
both  the  ascending  and  descending  colon  closely  sympathize  with  diseased 
structures  before  or  behind  them,  the  intestine  becomes  inactive,  the  pas- 
sage of  the  contents  impeded,  and  the  fulness  may  resemble  primary 
tumor  of  the  bowel. 

The  remaining  regions  are  the  hypogastric  and  the  right  and  left 
iliac. 

In  the  hypogastric  region  whenever  a  tumor  is  felt  we  must  always 
render  ourselves  sure  that  the  bladder  is  not  distended.  Urine  may  pass 
constantly,  in  fact,  there  may  be  a  constant  dribbling  from  over-distention 
of  the  bladder,  and  thus  the  disease  be  unsuspected.  In  this  way  I  have 
known  the  bladder  reach  above  the  umbilicus  and  contain  many  pints  of 
urine. 

2.  Enlargements  of  the  uterus,  whether  from  pregnancy  or  tumor,  ex- 
tend into  the  hypogastric  region. 

3.  Fibroid  tumors  of  the  uterus  and  of  the  ovaries,  and  cystiform  dis- 
ease of  the  ovaries,  extend  into  right  or  left  iliac  region,  and  also  into  the 
central  space. 

4.  Hydatid  disease  of  the  cellular  tissue  in  connection  with  the  blad- 
der forms  a  rounded  tumor  in  this  space,  in  touch  very  closely  resembling 
a  distended  bladder. 

6.  Aneurismal  disease  of  the  iliac  vessels  must  also  be  borne  in  mind 
as  a  cause  of  tumor  in  the  lateral  portions  of  the  hypogastric  region. 


ABDOMINAL   TUMORS.  2.39 

In  the  right  iliac  Teg'ion  we  have  the  caecum  and  its  appendix,  and  dis- 
eases of  these  structures  constitute  many  of  the  morbid  enlargements  at  this 
part.  The  mischief  may,  however,  be  external  to  the  caecum,  peri-typh- 
litis; in  these  diseases  we  have  local  pain  and  tenderness,  febrile  excite- 
ment, generally  a  disordered  condition  of  the  bowels,  constipation,  sick- 
ness, and  it  ma}  be  peritonitis.  In  tumor  from  enlarged  glands,  there  is 
less  interference  with  the  action  of  the  bowels.  In  pelvic  abscess  the 
bowel  is  free,  the  mischief  is  found  to  extend  from  above,  and  it  passes 
onwards  in  the  direction  of  the  psoas  and  iliacus  muscles.  A  tumor  from 
renal  disease  may  reach  the  iliac  fossa,  but  it  can  be  traced  upwards,  and 
the  urine  will  be  found  to  be  diseased  in  most  cases,  if  carefully  examined, 
except  in  instances  in  which  one  kidney  does  the  entire  work  and  the  other 
is  completely  shut  off. 

An  aneurismal  tumor  from  disease  of  the  iliac  vessels  is  recognized  by 
its  pulsatile  and  expansive  character,  and  by  the  condition  of  the  circu- 
lation of  the  limb. 

Ovarian  tiimors  reach  to  the  right  or  left  loin;  sometimes  they  become 
adherent  to  the  bowel,  and  I  have  known  an  ovarian  cyst  become  adherent 
to  the  caecum,  and  having  discharged  its  contents  into  the  bowel,  the 
cyst  has  become  filled  with  fsecal  matter.  Acute  disease  of  the  right 
ovary  sometimes  closely  resembles  typhlitis,  but  the  pain  is  lower,  it  ex- 
tends into  the  pelvis:  the  tenderness,  the  constipation,  the  febrile  excite- 
ment, may  be  equally  marked  in  the  acute  disease  of  the  ovary,  as  inciccal 
disease. 

In  the  left  iliac  region  many  morbid  growths  correspond  to  those  on 
the  right  side,  but  here  the  sigmoid  flexure  takes  the  place  of  the  caecum. 
The  curvature  of  this  part  of  the  bowel  varies  greatly;  sometimes  the  sig- 
moid flexure  extends  to  the  right  side,  and  there  may  be  adhesion  to  the 
caecum.  In  other  cases  of  distention  it  bends  upon  itself,  it  falls  into  the 
pelvis,  and  the  acute  bending  at  a  right  angle  leads  to  obstruction.  The 
termination  of  the  sigmoid  flexure  in  the  rectum  at  the  brim  cf  the  pelvis 
is  the  part  often  affected  by  disease,  and  a  tumor  can  in  most  cases  be 
made  out  by  careful  manipulation.  Sometimes  there  is  a  rounded  growth 
in  connection  with  the  mucous  membrane  of  the  bowel,  at  other  times  all 
the  coats  are  thickened  and  contracted,  as  if  a  piece  of  string  had  been 
tied  round  the  bowel;  all  these  states  lead  to  gradually  increasing  ob- 
struction, which  may  become  complete. 

Inflammatory  adhesion  sometimes  takes  place  between  the  sigmoid 
flexure  and  the  bladder;  an  external  tumor  is  felt  on  deep  but  gentle 
manipulation.  The  diagnosis  and  the  prognosis  of  these  cases  are  often 
very  obscure,  and  in  several  we  have  known  direct  communication  take 
place  with  the  bladder,  and  frecal  discharge  with  the  urine  supervene. 
Colotomy  is  of  the  greatest  service  in  these  cases. 

We  have  thus  briefly  sketched  the  site  and  the  character  of  abdominal 
tumors;  each  case  has  a  clinical  history  of  its  own.  and  it  is  by  the  care- 
ful study  of  that  history,  in  connection  with  the  position  of  the  tumor 
and  the  disturbances  of  the  functional  activity  that  are  associated  with  it, 
that  we  can  make  out  the  true  nature  of  the  disease.  Many  most  inter- 
esting cases  of  abdominal  tumor  might  have  been  added  to  this  chapter; 
the  difficulties  in  the  diagnosis  might  thereby  have  been  more  fully  indi- 
cated, and  the  various  modes  of  relief  discussed;  but  we  have  refrained 
on  account  of  the  length  to  which  this  work  has  already  extended,  and 
we  have  only  given  the  general  facts  which  these  instances  of  disease 
have  brought  out. 


240  DISEASES    OF   THE   INTESTINES    AND    PERITONEUM. 

We  have  sought  to  show  the  leading  characteristics  of  diseased  con- 
ditions as  manifested  in  the  various  portions  of  the  alimentary  canal;  and 
to  do  this  have  recorded  the  cases  themselves,  as  facts  upon  which  each 
one  may  form  his  own  opinion,  rather  than  depend  entirely  upon  the  de- 
ductions we  have  drawn  from  them.  Such  general  conclusions  in  most 
chapters  have  preceded  the  cases  upon  which  they  are  founded;  and  we 
leave  them  before  our  readers  with  the  hope  that  they  will  serve  further 
to  elucidate  the  general  symptoms,  pathology,  and  treatment  of  diseases 
of  the  alimentary  canal. 


INDEX. 


Abdomen,  affections  of  lymphatic  glands 
of,  323. 

Abdominal  tumors,  233. 

Abscess  of  the  liver,  in  dysentery,  100. 

Acids,  mineral,  in  the  treatment  of  diar- 
rhoea, 91. 

Adiiksions,  peritoneal  in  etiology  of  ob- 
struction of  duodenum,  122. 

Am,  pure  and  dry,  in  treatment  of  diar- 
rhoea, 89. 

Alkalies,  in  treatment  of  diarrhoea,  90. 

Anus,  diseases  of,  129  ;  congenital  imper- 
fections of,  129 ;  epithelioma  of,  148  ; 
prurigo  of,  150. 

AoKTA,  aneurism  of,  237. 

Appendix  vermipokmis,  diseases  of ,  65  ; 
ulceration  and  perforation  of,  67. 

AsCARis  lU-MBUicoides,  166 ;  symptoms 
and  diagnosis,  169 ;  prevention,  171 ; 
treatment,  170. 

ASCARIS  MYSPAX,  171. 

Ascites,  225;   etiology,  225;   symptoms, 

228;  treatment,  230. 
AsTuiNaENTS  in  treatment  of  diarrhoea, 

90. 
Atony  op  rectum,  148. 


Belly-ache,  1. 

Blood-letting  in  treatment  of  peritoni- 
tis, 205. 

botiiriocepnalus  cordatus,  165. 

latus,  164. 

Bowels,  obstruction  of,  18 ;  from  consti- 
pation, 18  ;  from  compression  and  trac- 
tion, 28 ;  from  internal  strangulation, 
30 ;  from  impaction  of  foreign  bodies, 
33 ;  from  intussusception,  35 ;  torsion 
or  twisting  of,  3z ;  principles  of  treat- 
ment, 48. 

,  ulceration  of,  51. 

Burns,  condition  of  mucous  membrane  of 
duodenum  after,  110. 


C^CUM,  diseases  of,  65;  ulceration  and 
perforation  of,  67. 

Cancer  op  duodenum,  119 ;  cases  of, 
120 ;  of  the  intestines,  61  ;  of  the  peri- 
toneum, 219;  of  the  rectum,  146. 

Colic,  1,  73;  etiology  of,  76;  pathology 
of,  75 ;  symptomatology  of,  73 ;  treat- 
ment of,  76. 

Colitis,  79. 

Colon,  cancerous  disease  of,  235. 

CoLOTOMY,  :s;39. 

Compression  and  traction  of  intestines, 
28 ;  pathology  of,  28 ;  symptoms  and 
treatment  of,  29. 

Constipation,  18 ;  causes  of,  22 ;  pathol- 
ogy of,  18;  symptoms  of,  18;  treat- 
ment of,  22  ;  as  a  symptom  of  obstruc- 
tion of  the  bowels,  45. 

Cysticercus  CELLULOSiE,  157;  centralis, 
159;  fasicolaria,  158;  pisiformis,  158; 
tenuicollis,  159  ;  taeniae  medio-canellatae, 
159. 

Demulcents  in  the  treatment  of  diar- 
rhoea, 90. 

Desiccants,  in  the  treatment  of  diarrhoea, 
90. 

Diarkikea,  81 ;  causes  of,  87 ;  catarrhal 
and  mucous,  83;  clioleraic,  81;  crapu- 
losa,  81;  dysenteric,  84;  melsenic  or 
bloody,  85  ;  prognosis,  88 ;  symptoms 
of,  86  ;  treatment  of,  89  ;   cases  of,  93. 

Dochmius  duodenalis,  173. 

Dropsy,  abdominal,  225. 

Duodenum,  anatomy  of,  107;  cancer  of, 
119;  condition  of  mucous  membrane  of, 
after  burns,  110;  congenital  malforma- 
tion of,  108  ;  congestion  of,  with  case, 
109  ;  gastric  solution  of,  128  ;  inflamma- 
tion of,  acute, 112  ;  mechanical  obstruc- 
tion of,  with  cases.  122 ;  state  of  secretion 
of,  108  ;  ulceration  of,  with  cases,  112, 
114. 


242 


INDEX 


Dysenteuy,  95  ;  acute,  96  ;  chronic,  98 ; 
etiology  of,  102;  history  of,  95;  mor- 
bid anatomy  of.  98  ;  symptomatology, 
9G;  treatment  of,  103. 

Enteu.\lgia,  1  ;  causes  of,  1  ;  diajpiosis 
of,  7 ;  pjitholo^'y  of,  5 ;  synonyms  of, 
1  ;  symptoms  of,  4  ;  treatment  of,  7. 

Enteritis,  9  ;  atfecting  the  serous  and 
musfular  coat-',  9;  affecting  the  mucous 
niembnme,  10;  affecting  the  whole 
tliicknetsof  the  bowel,  12  ;  treatment  of, 
15  ;  a  complication  of  peritoniuis,  196. 

EXCUESCENCES,  anal,  149. 

Fistula  in  ano,  140. 
Food  in  diarrhoea,  89. 
FouEiGN  BODIES,  in  etiology  of  obstruc- 
tion of  duodenum,  123. 

Gall-hi^adder,  enlargement  of,  235. 

Gai.i.- STONES,  in  etiology  of  obstruction 
of  duodenum,  122,  12  [. 

Ga-stric  juice,  perforation  of  duodenum 
by,  128. 

Gastritis,  a  complication  of  peritonitis, 
194. 

Glands,  enlarged,  in  etiology  of  obstruc- 
tion of  duodenum,  122. 

' lymphatic,  of  abdomen,  affections 

of,  223. 

Gripes,  1. 

Hii5MORRnorDS,  130;  symptoms,  132; 
triiatment,  138. 

Hepatitis,  a  complication  of  peritonitis, 
195. 

Hydatids  of  LiViiR,  in  etiology  of  ob- 
struction of  duodenum,  122,  127. 

Hystitis,  a  complication  of  peritonitis, 
196. 

Ileus,  1. 

Impaction  of  foreign  bodies,  intestinal, 
33 ;  cause  of,  34  ;  pathology  of,  33  ; 
symptoms  and  treatment  of,  35. 

Infiltration  and  thickening,  fibroid,  of 
the  intestine,  63. 

Inflammation,  catarrhal,  of  the  intes- 
tines, 10  ;  clironic,  of  the  intestines,  11  ; 
croupous,  of  the  intestines.  10. 

lNTE6i'lNi-.s,  cancerous  and  other  growths 


of,  61  ;  catarrhal  inflammation  of,  10; 
chronic  inflammation  of,  11 ;  compres- 
sion and  traction  of,  28 ;  croupous,  in- 
flammation of,  10 ;  degeneration  of,  11 ; 
dilatation  of,  20 ;  diseases  of  the  caecum 
and  appendix  vormiformis,  05  ;  fibroid 
infiltration  and  thickening  of,  63 ;  hy- 
pertrophy of,  20;  impaction  of  foreign 
bodies  in,  33 ;  inflammation  of,  9  ;  in- 
ternal strangulation  of,  30  ;  intussuscep- 
tion of,  35;  obstruction  of,  18;  polypi 
of,  63;  principles  of  treatment  in  ob- 
struction of,  48  ;  sequence  of  ulceration 
of,  56 ;  stricture  of,  23 ;  torsion  or 
twisting  of,  32;  treatment  of  inflam- 
mation of,  15 ;  ulceration  of,  beginning 
from  within,  51;  beginning  from  with- 
out, 57;  villous  growths  in,  63. 

Ipecac  in  treatment  of  diarrhoea,  90. 

Intussusception,  35:  condition  associ- 
ated with  development  of,  36 ;  length 
of  bowel  involved  in,  37 ;  pathology  of, 
35 ;  symptoms  of,  -10 ;  treatment  of, 
43. 

Kamela,  in  treatment  of  tape-worm,  161. 

Kidney,  enlargement  of,  233. 

Koueso,  in  treatment  of  tape-worm,  161. 

Leeciies,  in  the  treatment  of  diarrhoea, 
91. 

Life,  duration  of  in  obstruction  of  the 
bov.els,  4r. 

LivKR,  affection  of  in  dysentery,  100;  en- 
largement of,  2.5. 

Malefkrn   in   the    treatment    of    tape- 
j      worm,  160. 

I  Modi;  of  invasion,  in  obstructicm  of  the 
bowels,  47. 

Nephritis,  a  complication  of  peritonitis. 

196. 
Nervous  affections  ok  ri.ctum,  138. 
Neuralgia  of  tlie  rectum.  i;-9. 

Obstruction,  mechanical,  of  duodenum, 

122. 
Opium,  in  the  treatment  of  diarrhoea,  91 ; 

in  the  treatment  of  peritonitis,  206. 
OvAKlES,  enlargement  of,  237,  238. 
OxYLiUS  VE'tMICULARIS,  171. 


INDEX. 


243 


Pain  an  a  symptom  of  obstruction  of  the 
bowels,  44. 

PauaCilntesis  in  the  treatment  of  ascites, 
231. 

Panckeas,  diseased,  in  etiology  of  obstruc- 
tion of  duodenum,  i2i,  VZii  ;  malignant 
disease  of,  2:}5. 

Pkkitoneum,  carcinoma  of,  219  ;  tubercle 
of.  213. 

PiiKiTONlTis,  177 ;  etiology  and  symp- 
toms, 179 ;  non-plastic  or  erysipela- 
tous, 183  ;  perforating.  184  ;  puerperal, 
190  ;  of  children,  193 ;  complications  of, 
194 ;  morbid  anatomy  of,  197 ;  diag- 
nosis of,  202 ;  prognosis,  204 ;  treat- 
ment of,  20;). 

acute,  in  etiology  of  ascites, 

225  ;  tubercular,  218. 

Perityphlitis,  C7;  pathology  of,  67; 
symptoms  of,  69;  treatment  of,  71, 
192. 

PUANTOM  TUMORS,  2;')3. 

Pi!.ES,  130  ;    symptoms,  132  ;  treatment, 

133. 
Polypi,    intestinal,    63;    of  the  rectum, 

139. 
Pomegranate  uauk  in  the  treatment  of 

tape- worm,  160. 
Prurigo  ani,  150. 

Rectum,  atony  of,  148;  cancer  of,  146; 
chronic  ulceration  of,  142  ;  congenital 
imperfections  of,  129;  diseases  of,  129  ; 
epithelioma  of,  148  ;  fistula  of,  140 ;  ir- 
ritable, 138  ;  irritable  sphincter,  muscle 
of,  137 ;  irritable  ulcer  and  fissure  of, 
136 ;  morbid  sensibility  of,  138  ;  ner- 
vous afftctions  of,  138;  neuralgia  of, 
139  ;  polypi  of,  139  ;  prolapsus  of,  131 ; 
stricture  of,  113  ;  villous  tumor  of,  139. 

Rest,  in  the  treatment  of  diarrhcEa,  89. 

Skat-worm,  171. 

Sphincter,  irritable,  of  rectum,  137. 

Splenitis,  a  complication  of  peritonitis, 
195. 

Statistics,  facts  derivable  from,  in  ob- 
struction of  the  bowels,  48. 

Stimulants,  avoidance  of,  in  diarrhoea, 
89. 


Stuanoulation,  internal,  of  the  intes- 
tines, 30 ;  pathology  of,  30  ;  symptoms 
and  trextinent  of,  31. 

Stricture  of  the  intestines,  23;  fre- 
quency in  different  parts,  25  ;  pathology 
of,  23 ;  seat  of,  26  ;  symptoms  of,  25 ; 
treatment  of,  27  ;  of  the  rectum,  143. 

SuppDt^iTORiES,  in  the  treatment  of  diar- 
rhcea,  91. 

SUPRA-UESAL   capsule,  235. 

T..ENIA,  ccenurans,  159  ;  crassicolles,  158; 
marginata,  159  ;  medio-canellata,  159  ; 
serrata,  158. 

elliptica,  163  ;  flavo-punctata,  163  ; 


medio-canellata,  161  ;  nana,  163. 

SOLIUM,    15G ;     symptoms,     159 ; 


diagnosis,  etiology,  pathology,  and  treat- 
ment, 160. 
Thread-worm,  171. 
Tormina,  1. 

Tricocepiialus  dispar,  174. 
Tubercle,  in  etiologj'  of  ulceration    of 

the  intestines,  55  ;  of  the  peritoneum, 

213. 
Tumors,  abdominal,  233 ;  anal,  149. 
Tu.MOR  AND  su.vPE    of    the    belly   as    a 

symptom  in  obstruction  of  the  bowels, 

45. 
Typhoid  fever,  in  etiology  of  ulceration 

of  the  intestines,  54. 
Typhlitis,    pathology  of,  67;  symptoms 

of,  69  ;  treatment  of,  71. 

Ulceration  of  the  bowels,  51 ;  pathology 

of,  51  ;  symptoms  of,  58;  treatment  of, 

59. 

chronic,  of  the  rectum,  142 ; 


of  the  duodenum,  table,  1 19. 
UitiNE,  condition  of  in  obstruction  of  the 

bowels,  46. 
Uterus,  enlargements  of,  238. 

Villous    tumor    of  the    rectum,    139; 

growths,  intestinal,  63. 
Vomiting  as  a  symptom  of  obstruction  of 

the  bowels,  44. 

Warmth,  in  the  treatment  of  diarrhoea, 

89. 
Worms,  intestinal,  153. 


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